SummaryVeteran Affairs medical centers participating in a clinical trial used mental health practitioners to provide smoking cessation counseling and treatment to patients with posttraumatic stress disorder as part of their regular mental health care. Using well-established practices and interventions, these practitioners provided five weekly core sessions focused on building skills that aid in quitting, three followup visits focused on preventing and managing relapses, and at least monthly "booster" sessions to assess smoking status and intervene as necessary. The program enhanced access to treatment, which, in turn, increased short- and long-term quit rates without detracting from the effectiveness of mental health treatment.Strong: The evidence consists of a randomized controlled trial comparing key measures in 472 program participants and 471 similar patients receiving a referral to an onsite smoking cessation clinic within the same VA facilities. Measures include number of treatment sessions attended, use of smoking cessation medications, short- and long-term rates of abstinence, time to relapse to smoking, psychiatric symptoms, and serious adverse events.
Developing OrganizationsU.S. Department of Veteran Affairs
Use By Other OrganizationsThe VA medical center in Minneapolis is using the manual to implement this program in its general mental health clinic.
Date First Implemented2004
Small-scale studies of the program began in 2002 at the Veterans Affairs Puget Sound Health Care System in Seattle. Recruitment for the multisite trial began in November 2004 and continued until December 2007.
Patient PopulationThe multisite clinical trial included cigarette smokers being treated for posttraumatic stress disorder (PTSD) in outpatient mental health clinics at 10 Department of Veterans Affairs (VA) medical centers.Vulnerable Populations > Military/dependents/veterans
Problem AddressedMany individuals with mental illness, including PTSD, become addicted to tobacco. Tobacco dependence accounts in part for disproportionately high rates of health care utilization, morbidity, and mortality in veterans with PTSD. Mental health practitioners represent a potentially effective but underutilized resource for providing smoking cessation treatment to these individuals.
- Strong link between PTSD and nicotine dependence: Almost half (45 percent) of individuals with PTSD smoke (well above the roughly 20 percent in the general population who do so) and smokers with PTSD are far less likely to succeed in quitting than smokers without PTSD.1,2 Smokers with PTSD tend to smoke more heavily than the average smoker and use tobacco to regulate their mood and psychiatric symptoms.3
- Leading to negative health outcomes: Cigarette smoking likely contributes to high rates of morbidity3 and mortality4 among individuals with PTSD as well as high health care utilization5 and costs for those with PTSD.
- Limited delivery of cessation treatment: Established treatments, including medication and counseling, can be effective in helping smokers quit. But relatively few smokers receive such treatment. Studies show that while primary care providers may inquire about smoking, most patients who smoke do not receive smoking cessation treatment from them.6 Moreover, relatively few smokers receive referrals to specialized clinics that can assist in quitting7 and those referred to such programs often fail to attend or drop out early.8
- Unrealized potential of mental health providers: Mental health practitioners are ideally positioned to deliver effective tobacco cessation treatment to smokers because of their training and skills in behavioral health and substance use treatment. Mental health clinicians can routinely monitor their patients’ smoking status, identify and therapeutically respond to nicotine withdrawal symptoms, and manage relapses by reapplying cessation treatment in a timely manner. (Relapse occurs more frequently than not, even in those ultimately successful in quitting.) Unfortunately, few smokers engaged in mental health treatment receive such tobacco cessation interventions from their mental health practitioners, as illustrated in a study showing that only 12 percent of smokers seeing a psychiatrist received cessation counseling.9 Among the 400,000 veterans with PTSD enrolled in the VA, those who smoke (30 to 45 percent) and see mental health providers could potentially benefit from cessation services integrated into routine psychiatric care.
Description of the Innovative ActivityVA mental health clinics provide smoking cessation counseling and treatment to PTSD patients as part of regular mental health services. Using a manual that adheres to established tobacco cessation practices10 and specific interventions to address PTSD symptoms related to relapse, practitioners provide five weekly core sessions focused on building skills that help in quitting, three followup visits focused on preventing and managing relapses, and at least monthly "booster" sessions to assess smoking status and intervene as necessary. Core recommended program elements are detailed below:
- Identification of smokers at weekly meeting: As part of regularly scheduled staff meetings to discuss the clinical status of patients in PTSD clinics, practitioners identify smokers and formulate treatment plans to provide cessation counseling and pharmacological treatment for nicotine dependence.
- Flexible timing: Clinicians—usually psychologists or social workers—work with the patient to determine the appropriate time to introduce smoking cessation treatment into PTSD therapy. Some patients want to tackle smoking right away, seeing it as a narrow, achievable issue that can be effectively addressed (in contrast to more difficult issues, such as dealing with war-induced trauma). Other patients have more urgent crises that must be addressed first and/or do not feel ready to give up smoking until they have their PTSD symptoms under control. (Smoking often serves as a way of coping with psychiatric symptoms.) During the initial trial of this program, participants received the intervention within 3 months of the start of the program.
- Cessation treatment as part of ongoing care: Once a patient appears ready to try to quit smoking, clinicians integrate cessation treatment into their ongoing mental health care. Most sites integrate smoking cessation into regularly scheduled individual sessions with patients. However, as research findings are translated into clinical practice in VA settings, some sites have begun to integrate tobacco cessation into group-based sessions. Regardless of the venue used, integrated tobacco cessation treatment consists of the following:
- Core sessions: For 5 consecutive weeks, clinicians spend roughly 30 minutes focusing on education and building skills related to quitting, including how to identify triggers leading to smoking (e.g., meals, drinking coffee, talking on the phone) and how to address these triggers, such as by engaging in alternative behaviors. Sessions also focus on identifying and mobilizing social support systems, such as spouses or friends (including those who have quit smoking), because those with such support tend to fare better. During these sessions, patients generally set a quit date (typically aiming to quit after the fifth session) and learn strategies for preventing relapse. Patients are encouraged but not required to see a psychiatrist or nurse practitioner to obtain U.S. Food and Drug Administration–approved smoking cessation medications based on an established algorithm, and to begin taking them at the appropriate time based on the chosen quit date.
- Followup visits: After the core sessions, clinicians spend roughly 15 minutes on smoking cessation during the next 3 regularly scheduled sessions. These visits focus on preventing and managing relapses. Relapse prevention strategies include developing a plan to deal with specific stressful situations, such as a certain time of the year (e.g., the holidays, an anniversary). Relapse management focuses on helping patients not blame themselves (which only makes them feel worse and hence more likely to smoke) and learn from their mistakes to avoid future lapses. Clinicians reapply treatment components as they deem necessary, including making medication or dosage adjustments in consultation with the psychiatrist or nurse practitioner, and revisiting skills learned in the core sessions.
- At least monthly "booster" sessions: After the followup visits, the clinician periodically provides brief (5-minute) "booster" sessions to assess current smoking status and reapply counseling or treatment as necessary. These sessions focus on preventing and managing relapses by reengaging the patient. Having this discussion regularly helps to create the expectation that smoking is a chronic condition that requires ongoing management, and that cessation treatment only ends when the patient gives up smoking permanently. The intent is for these brief booster sessions to occur at least monthly for as long as the patient remains in mental health treatment.
Context of the InnovationThe VA provides care to approximately 400,000 veterans with PTSD. The impetus for this program came from a growing realization among leaders at the VA Puget Sound Health Care System in Seattle, WA, that the current system to provide cessation treatment to smokers with PTSD was not optimally effective. Even as the VA had made tremendous progress in reducing tobacco use among all veterans in the last decade (with smoking rates having fallen from 32 percent to just under 20 percent), roughly 40 percent of veterans with mental illness still smoked. These leaders felt that mental health providers within the VA system represented the best vehicle for delivering effective, ongoing treatment to patients enrolled in psychiatric care for PTSD, following principles of a chronic disease management approach. To that end, they began testing the program on a small scale in the Seattle area and then on a larger scale at 10 VA medical centers across the United States. (See the Planning and Development Process section for more information.)
ResultsThe integrated smoking cessation program enhanced access to a therapeutic dose of cessation treatment and significantly increased short- and long-term quit rates, as compared with referral to a specialized smoking cessation clinic (VA's usual care). The program did not interfere with the effectiveness of PTSD treatment or lead to any worsening of patients' psychiatric outcomes.
Strong: The evidence consists of a randomized controlled trial comparing key measures in 472 program participants and 471 similar patients receiving a referral to an onsite smoking cessation clinic within the same VA facilities. Measures include number of treatment sessions attended, use of smoking cessation medications, short- and long-term rates of abstinence, time to relapse to smoking, psychiatric symptoms, and serious adverse events.
- Enhanced access to therapeutic dose of treatment: Those receiving integrated care attended a median of eight cessation sessions, compared to just one session for those referred to an onsite clinic specializing in tobacco cessation treatment. Program participants also had more days of using prescribed tobacco cessation medications, including combination medication therapy.11
- Higher prolonged abstinence: Program participants were more than twice as likely to report prolonged abstinence from smoking in the past year (between 6 and 18 months after the program ended) than those in the control group (15.5 vs. 7 percent). Biological testing showed a similar pattern, with 8.9 percent of participants confirmed in prolonged abstinence over this 12-month period, compared with 4.5 percent of those receiving a referral. The true quit rate likely lies somewhere between these two figures, as some of those reporting that they quit whose biological testing indicated otherwise may have been exposed to carbon monoxide or nicotine in the environment.11
- Higher short-term abstinence: Program participants consistently exhibited a greater likelihood of having not smoked in the past 7 and 30 days (both in self-reports and biological verification) than did those referred to a specialized facility. This pattern held for every 3-month measurement point over an 18-month period following randomization to one of the two groups. For example, 18.2 percent of program participants had not smoked in the last 7 days after 18 months, compared with 10.8 percent of those in the control group.11
- Longer time to relapse: Among those who made a 24-hour or longer quit attempt, program participants took longer to relapse than those in the comparison group, with the median time to relapse being 29 days in program participants, compared with 8 days in the control group.11
- No negative effect on psychiatric outcomes: Prior research suggests that quitting smoking can exacerbate mental health conditions. However, program participants who quit smoking did not show any worsening of psychiatric symptoms (PTSD or depression). In fact, in aggregate, study participants showed a statistically significant improvement in PTSD symptoms over 18 months.11
- Future evaluation of long-term outcomes, cost-effectiveness: Once completed, ongoing analyses will shed light on this program's impact on long-term (48-month) patient outcomes and on the cost-effectiveness of this approach.
Planning and Development ProcessKey steps included the following:
- Development of treatment program manual: Program leaders created a treatment manual for providers and companion workbook for patients based on established clinical practice guidelines developed by various organizations, including those in the field of public health and the military (i.e., the VA and Department of Defense). They designed and customized these materials to accommodate the unique needs of veterans with PTSD; to that end, they included an appendix on how to manage psychiatric problems often exacerbated by smoking cessation, such as anxiety, difficulty concentrating, and other mood-related problems. Several tobacco cessation experts reviewed, provided input into, and endorsed the manual.
- Small-scale pilot test: Program developers tested the manual and the broader concept of having mental health clinicians provide cessation treatment on a small scale at two VA clinics in the Seattle area. This pilot work found the integrated care approach to smoking cessation to be superior to the traditional strategy of referring patients to a specialty smoking cessation clinic within the VA.
- Large-scale, multisite trial: Based on the success of the small-scale pilot, program developers received funding from the VA Cooperative Studies Program to conduct a 10-site randomized, controlled clinical effectiveness trial with participating VA medical centers around the country, including facilities in Houston, Hampton (VA), Minneapolis, New Orleans, Philadelphia, Portland (OR), Providence, San Diego, Tuscaloosa, and Washington, DC. Developers sought and received approval from the Human Rights Committee of the Palo Alto Cooperative Studies Program Coordinating Center and institutional review boards at participating sites.
- Training via "train-the-trainer" approach: Leaders at each of the 10 participating VA medical centers received roughly 4 hours of training on how to deliver smoking cessation counseling and pharmacological treatment to patients. Training included a review of the manual, role playing, and session "walk-throughs." These leaders then took responsibility for training relevant clinicians within their facilities, typically through 2- to 4-hour locally held workshops. Mayo Clinic experts validated the effectiveness of such training by reviewing audiotapes of actual sessions, finding 85 percent of those who submitted tapes (representing 92 percent of all PTSD clinic providers) to be competent in treatment delivery (10 percent were not found competent, while 5 percent of tapes were inaudible).11
- Program expansion: Based on the success of the multisite trial, the VA Strategic Health Care Group provided funding to spread the program to other VA sites. This effort, still in a preliminary stage of development, has taken the form of a "learning collaborative" to train mental health providers at six VA PTSD programs to deliver integrated smoking cessation treatment to veterans with PTSD under their care. Many sites that participated in the large-scale clinical research trial continue to offer the program as well, although site leaders remain free to use and adapt it as they see fit. According to information provided in June 2013, the VA Public Health Strategic Healthcare Group funded additional implementation of the program; from 2010 through 2012, two successive waves of six VA PTSD program staff members were trained in integrated care and were given assistance in implementation and sustainability using methods adapted from the Breakthrough Series. In total, 111 mental health providers were trained to deliver the intervention, and 535 veterans with PTSD received integrated care for smoking cessation.
Resources Used and Skills Needed
- Staffing: The program requires no new staff, as existing mental health clinicians (typically psychologists with doctorate degrees and master's-level social workers) provide smoking cessation treatment as part of already scheduled visits. Psychiatrists and nurse practitioners already embedded in VA PTSD clinics assume responsibility for prescribing tobacco cessation medications. For those sites offering group-based PTSD therapy, smoking cessation treatment may sometimes require scheduling of additional individual sessions. PTSD therapists providing individual psychotherapy to patients who smoke may "carve out" time from their usual session content to address nicotine addiction. PTSD clinic staff delivering tobacco cessation therapy should ideally devote roughly 2 to 4 hours to reviewing and learning smoking cessation methods detailed in the treatment manual and participant workbook.
- Costs: Program-related expenses are minimal, consisting primarily of the staff time needed for learning tobacco cessation treatment methods. Depending on the approach PTSD clinicians use to deliver integrated care, additional treatment sessions over and above those required to address PTSD symptoms alone may be required. The program may result in higher smoking cessation treatment costs (including medication costs) as more patients receive access to such services. As noted earlier, an ongoing analysis will evaluate the cost-effectiveness of the approach.
Funding SourcesU.S. Department of Veteran Affairs Cooperative Studies Program
Getting Started with This Innovation
- Identify and cultivate local champions: Each adopting site needs a champion with enthusiasm for the program and a willingness to train clinicians on how to provide smoking cessation services. (During the multisite trial, program developers required PTSD clinic team leaders to play this role.) Many mental health professionals view offering tobacco cessation services as outside their area of responsibility, an unwelcome demand on their limited time, or a source of frustration given low success rates. Consequently, the local champion needs to explain clearly and convincingly the rationale for the program and assure clinicians that tobacco cessation services represent one of the most effective ways to improve their patients' quality of life and longevity. The champion can coach providers in program development modifications so that tobacco cessation interventions can be easily accommodated within their treatment plan with patients. He or she can also provide education and support to encourage fellow clinicians to make smoking cessation a priority.
- Leverage existing resources with interested clinicians: Some mental health clinicians will likely feel quite comfortable offering smoking cessation treatment, as they already know how to work with patients on substance abuse disorders and behavioral issues. The VA manual (available from the program developer) can help in getting the program up and running quickly with these clinicians. After launching the program on a small scale, would-be adopters can evaluate the approach, refine it as needed, and spread the program to others over time.
Sustaining This Innovation
- Make smoking inquiries part of organizational culture: Inquiries about smoking status and interest in quitting need to become part of the organization's "vital signs," ideally being discussed at every patient intake meeting and, to the extent possible, every patient–clinician encounter. To make this occur, clinic leaders need to regularly reinforce the importance of smoking cessation as a health care priority.
- Integrate smoking cessation into student training: Academic medical centers and other teaching organizations that adopt this program should consider making education about smoking cessation a part of the training experience for nursing students, psychology interns, psychiatry residents, and other future mental health professionals.
Use By Other OrganizationsThe VA medical center in Minneapolis is using the manual to implement this program in its general mental health clinic.
- Consider strategies to boost participation by younger veterans: Younger veterans have the most to gain from participating (because quitting at a younger age helps to avoid many smoking-related health problems), but often lack the time or inclination to participate in face-to-face sessions. For example, during the multisite trial of this program, younger veterans—particularly those who served in Iraq or Afghanistan—had higher dropout rates. Several strategies could potentially boost their participation, such as telehealth- or Internet-based services (which take less time and improve access to care) and/or tangible rewards for attendance or success in quitting.
- Consider use with other populations: Although this program has only been tested with PTSD patients, program developers believe that a similar approach could work with veterans and nonveterans with other mental illnesses.
Contact the InnovatorMiles McFall, PhD
Veteran Affairs Puget Sound Health Care System
1660 S Columbian Way, S-116 MHC
Andrew J. Saxon, MD
Veteran Affairs Puget Sound Health Care System
1660 S Columbian Way, S-116 MHC
Innovator DisclosuresDr. McFall reported having no financial interests or business/professional affiliations relevant to the work described in this profile.
Dr. Saxon reported receiving payments for being on the board of directors of the Alkermes, Inc. and for speaking engagements from the Reckitt Benckiser, Inc.
References/Related ArticlesMcFall M, Saxon AJ, Malte CA, et al. Integrating tobacco cessation into mental health care for posttraumatic stress disorder. JAMA. 2010;304(22):2485-93. [PubMed]
McFall M, Saxon AJ, Thompson CE, et al. Improving the rates of quitting smoking for veterans with posttraumatic stress disorder. Am J Psychiatry. 2005;162(7):1311-9. [PubMed]
Ziedonis D, Hitsman B, Beckham JC, et al. Tobacco use and cessation in psychiatric disorders. Nicotine Tob Res. 2008;10(12):1691-1715. [PubMed]
Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness: a population-based prevalence study. JAMA. 2000;284(20):2606-10. [PubMed]
Beckham JC, Kirby AC, Feldman ME, et al. Prevalence and correlates of heavy smoking in Vietnam veterans with chronic posttraumatic stress disorder. Addict Behav. 1997;22(5):637-47. [PubMed]
Boscarino JA. Posttraumatic stress disorder and mortality among U.S. Army veterans 30 years after military service. Ann Epidemiol. 2006;16(4):248-56. [PubMed]
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Sherman SE, Yano EM, Lanto AB, et al. Smokers' interest in quitting and services received. Am J Med Qual. 2005;20(1):33-9. [PubMed]
Sherman SE, Yano EM, York LS, et al. Assessing the structure of smoking cessation care in the Veterans Health Administration. Am J Health Promot. 2006; 20(5):313-8. [PubMed]
9 Goldman R, Craig T. VHA smoking cessation treatment: findings from national patient surveys and medical record reviews [newsletter]. National Association of VA Ambulatory Care Managers. 2004;15:6.
Himelhoch S, Daumit G. To whom do psychiatrists offer smoking-cessation counseling? Am J Psychiatry. 2003;160(12):2228-30. [PubMed]
11 Fiore MC, Jaen CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update: Clinical Practice Guideline. Rockville, MD: U.S. Dept. of Health and Human Services; 2008.
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Original publication: April 27, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: April 14, 2014.
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