Integrating tobacco cessation into mental health care for posttraumatic stress disorder: a randomized controlled trial

Abstract

Context: Most smokers with mental illness do not receive tobacco cessation treatment.

Objective: To determine whether integrating smoking cessation treatment into mental health care for veterans with posttraumatic stress disorder (PTSD) improves long-term smoking abstinence rates.

Design, setting, and patients: A randomized controlled trial of 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.

Intervention: Smoking cessation treatment integrated within mental health care for PTSD delivered by mental health clinicians (integrated care [IC]) vs referral to Veterans Affairs smoking cessation clinics (SCC). Patients received smoking cessation treatment within 3 months of study enrollment.

Main outcome measures: Smoking outcomes included 12-month bioverified prolonged abstinence (primary outcome) and 7- and 30-day point prevalence abstinence assessed at 3-month intervals. Amount of smoking cessation medications and counseling sessions delivered were tested as mediators of outcome. Posttraumatic stress disorder and depression were repeatedly assessed using the PTSD Checklist and Patient Health Questionnaire 9, respectively, to determine if IC participation or quitting smoking worsened psychiatric status.

Results: Integrated care was better than SCC on prolonged abstinence (8.9% vs 4.5%; adjusted odds ratio, 2.26; 95% confidence interval [CI], 1.30-3.91; P = .004). Differences between IC vs SCC were largest at 6 months for 7-day point prevalence abstinence (78/472 [16.5%] vs 34/471 [7.2%], P < .001) and remained significant at 18 months (86/472 [18.2%] vs 51/471 [10.8%], P < .001). Number of counseling sessions received and days of cessation medication used explained 39.1% 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. Nonquitters worsened slightly on the Patient Health Questionnaire 9 relative to quitters (differences ranged between 0.4 and 2.1, P = .03), whose scores did not change over time.

Conclusion: Among smokers with military-related PTSD, integrating smoking cessation treatment into mental health care compared with referral to specialized cessation treatment resulted in greater prolonged abstinence.

Trial registration: clinicaltrials.gov Identifier: NCT00118534.

Figure 1

Flow of Patients PTSD indicates posttraumatic stress disorder. Numbers of patients determined to be ineligible or declining participation prior to screening were not tracked. Eight patients were screened (n=6) or randomized (n=2) but not included here due to issues with informed consent, Health Insurance Portability and Accountability Act authorization, or both. ^aNumbers sum to more than the total because multiple categories could be checked. ^bFinal visit ranged between 18 and 48 months. Patients were followed up for a minimum of 18 months and until the end of the study.

Figure 2. Seven- and 30-Day Point Prevalence Abstinence by Treatment Condition

Error bars indicate 95% confidence intervals. Data are based on all 943 randomized patients. Patients with missing data were presumed to be nonabstinent. Data at the 3-, 6-, 9-, 12-, 15-, and 18-month assessments were collected an average of 96, 187, 280, 370, 461, and 566 days after randomization, respectively.

Figure 3. Months to Relapse Following Initial 24-Hour Quit Between Randomization and 18-Month Assessment (n=682)

HR indicates hazard ratio; CI, confidence interval. A total of 111 patients from integrated care and 150 patients from smoking cessation clinic did not quit smoking for 24 hours between randomization and 18 months and were not included in the analysis. Time to relapse from first 24-hour quit was longer in integrated care than in smoking cessation clinic (stratified by quartiles of time to quit; log-rank test; ${\chi }_1^2=14.53$; P <.001).