Veterans’ Program Integrating Smoking Cessation With PTSD Treatment Expands

A program for veterans with post-traumatic stress syndrome (PTSD) that integrates smoking cessation into mental health care, which was found effective in a study published last year, is now being used in six Veterans Affairs (VA) medical centers around the country.

Until now, many veteran smokers with PTSD have not been receiving help in quitting smoking, says one of the study’s authors, Andrew J. Saxon, M.D., Director of the Addiction Psychiatry Residency Program at the University of Washington and Director of the Addiction Patient Care Line at the VA Puget Sound Health Care System in Seattle. Those veterans who do receive help are often referred to VA smoking cessation clinics, where many fail to attend or drop out of the program early, he says.

He cites a study noting that of the more than 1.5 million veterans with mental illness, including more than 400,000 with PTSD, the majority of smokers report not receiving tobacco cessation treatment during the previous year.

“Smoking is not addressed much throughout mental health care,” Dr. Saxon said. “When I was first practicing psychiatry in the mid-1980s, smoking was almost encouraged among veterans we were treating. Today, it’s still largely tolerated because many mental health providers are concerned that quitting smoking may destabilize their patients.”

Quitting Smoking Doesn’t Make PTSD Worse

The study conducted by Miles McFall, Ph.D, Dr. Saxon, and other colleagues, published in the Journal of the American Medical Association in December 2010, found that was not the case. The authors looked at 943 smokers with military-related PTSD who were followed for 18 to 48 months. They were randomly assigned to either receive smoking cessation services as part of their mental health treatment (known as integrated care) or were referred to a VA smoking cessation clinic.

The integrated care group received five weekly core tobacco cessation sessions focusing on issues including behavioral skills for quitting, setting a quit date and relapse prevention. Participants were offered cessation medications. The veterans also had follow-up visits. All of these sessions were typically incorporated into their regularly scheduled PTSD visits.

While quit rates for both groups were low, the veterans in the integrated care group were almost twice as likely to quit as those receiving stand-alone smoking cessation treatment (8.9 percent vs. 4.5 percent). Symptoms of PTSD improved for both groups and were similar at the end of the study. “This shows that quitting smoking didn’t harm them in terms of their mental health status,” Dr. Saxon said.

He notes that quit rates from the study were lower than those typically found for non-mentally ill smokers, because smokers with mood and anxiety disorders often are more nicotine-dependent and more likely to relapse following treatment.

Learning Collaborative at Six Sites

Now the VA is funding a learning collaborative at six VA sites with PTSD programs to implement the findings of the study. Dr. Saxon and colleagues are training providers to deliver integrated smoking cessation care to their PTSD patients. The program is being used in the following VA health systems: Palo Alto, CA, Black Hills, SD, Sioux City, IA, Cleveland, OH, Durham, NC and North Texas (Dallas).

While much of the integrated care program could be used by anyone who is trying to quit smoking, Dr. Saxon says it includes information specific to people with PTSD, such as how to teach controlled breathing to deal with anxiety, as well as modules on nightmares and PTSD flashbacks.  Dr. Saxon says he believes that the same manual has the potential to be useful for the estimated 10 million Americans who receive mental health treatment—about 40 percent of whom smoke. But the program has not yet been studied in people with mental illness other than PTSD.

Both the U.S. Department of Veterans Affairs and the Department of Defense are very interested in changing the culture of smoking in the military, Dr. Saxon said. According to a 2009 Institute of Medicine report, “Combating Tobacco Use in Military and Veteran Populations,” tobacco use adversely affects military readiness; harms the health and welfare of active-duty military and veterans; and costs the nation millions in health care spending and lost productivity each year. The report notes that in 2005, an estimated 32 percent of active-duty military personnel smoke, compared with just over 20 percent of the U.S. adult population. The prevalence of smoking is over 50 percent higher in military personnel who have been deployed than in those who have not.

“We started the study because 45 percent of PTSD patients smoke and their smoking often isn’t addressed,” he said. “That means that they are developing medical disorders that are at least partly driven by their smoking. If we help young Iraq and Afghanistan veterans with PTSD to quit smoking now, we could prevent many long-term health problems.”