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

A review of smoking cessation interventions for smokers aged 50 and older

OBJECTIVES

Cigarette smoking poses substantial health risks at any age, but is particularly dangerous for older smokers, who are already at heightened risk for various health conditions. Studies suggest that older smokers are motivated to quit and succeed, but few of these have been randomized controlled trials. There is a need to systematically evaluate the research on effective interventions in older smokers.

METHODS

We followed PRISMA guidelines in the development of this systematic review, which included randomized controlled trials of cessation interventions with smokers aged 50 or older.

RESULTS

We found 740 unique titles matching specified search criteria; 13 met final eligibility criteria. Nearly all the cessation treatments combined counseling with other strategies. Eight studies provided smoking cessation medications. None of the studies used newer forms of technology such as web- or text-based interventions. Nine of the 13 studies reported a significant intervention effect at one or more time points, with three studies reporting sustained treatment effects at 12 mos or longer. In general, more intensive interventions and those with combined approaches including medications and follow-up counseling achieved the best outcomes.

CONCLUSION

The quit rates from these studies and the relative effectiveness of different intervention approaches are consistent with the general smoking cessation literature. However, in most studies, treatment effects were of short duration, and absolute quit rates were low, leaving the vast majority of older smokers at high risk for smoking-related health conditions. This systematic review suggests a need for additional research to design and test future interventions specifically tailored for older smokers.

Tobacco and marijuana use among adolescents and young adults: a systematic review of their co-use

Tobacco (TOB) and marijuana (MJ) are the most widely used drugs among adolescents and young adults. The literature on their co-use, however, has not been systematically reviewed. We identified 163 English language articles published from 1999 to 2009 examining TOB and MJ co-use, correlates or consequences of co-use, or interventions for prevention or cessation of co-use with participants aging 13-25 years. Most studies (n=114, 70%) examined TOB and MJ co-use, and 85% of relationships studied indicated a significant association. Fifty-nine studies (36%) examined correlates or consequences of co-use. Factors consistently associated with increased likelihood of co-use, defined as significant associations in at least four studies, were African-American ethnicity, mental and physical health characteristics (e.g., high-intensity pleasure temperament), and school characteristics (e.g., good grades). The only consistent consequence of co-use was exacerbation of mental health symptoms. Few studies examined prevention (n=3) or cessation (n=2) interventions for TOB and MJ co-use, and the findings were stronger for prevention efforts. A sufficient literature base has documented that TOB and MJ use are strongly related in young people, yet few consistent correlates and consequences of co-use have been identified to inform intervention targets.

Promoting smoke-free environments and tobacco cessation in residential treatment facilities for mental health and substance addictions, Oregon, 2010

We assessed tobacco-related policies and procedures at all state-funded, community-based residential mental health and substance addiction treatment facilities before implementation of new state policy requirements. We conducted telephone interviews with 162 of 166 (98%) facility administrators. Only 15% had voluntarily implemented 100% smoke-free campus policies, and 47% offered cessation resources at patient discharge; however, less than 10% expressed opposition to these future requirements. Smoking bans and cessation support in residential treatment facilities can reduce tobacco-related disparities among people with mental illness and addictions, but states may need to be the catalyst for policy implementation.

The influence of posttraumatic stress disorder numbing and hyperarousal symptom clusters in the prediction of physical health status in veterans with chronic tobacco dependence and posttraumatic stress disorder

Smoking and PTSD are predictors of poor physical health status. This study examined the unique contribution of PTSD symptoms in the prediction of the SF-36 physical health status subscales accounting for cigarette smoking, chronic medical conditions, alcohol and drug use disorders, and depression. This study examined baseline interview and self-report data from a national tobacco cessation randomized, controlled trial (Veterans Affairs Cooperative Study 519) that enrolled tobacco-dependent veterans with chronic PTSD (N = 943). A series of blockwise multiple regression analyses indicated that PTSD numbing and hyperarousal symptom clusters explained a significant proportion of the variance across all physical health domains except for the Physical Functioning subscale, which measures impairments in specific physical activities. Our findings further explain the impact of PTSD on health status by exploring the way PTSD symptom clusters predict self-perceptions of health, role limitations, pain, and vitality.

Inflammation and traumatic stress: the society to cells resiliency model to support integrative interventions

BACKGROUND

Posttraumatic stress disorder (PTSD) is a prevalent psychiatric disorder that develops following a traumatic event and has substantial health implications, including high rates of health morbidity and mortality, as well as significant health-related costs. Medical risks that are associated with PTSD often have an underlying inflammatory pathology, suggesting that inflammation contributes to these health declines.

OBJECTIVES AND DESIGN

In this critical literature review, the authors examine the medical risks associated with PTSD and the inflammatory mechanisms that likely underlie these risks.

RESULTS AND CONCLUSIONS

The authors offer a review of their "Cells to Society Resiliency Model" to motivate the development of integrative interventions that include factors of society, community, family, individual, physiological, and cellular factors to thereby reduce the health risks associated with PTSD.

Nicotine dependence and its risk factors among users of veterans health services, 2008-2009

INTRODUCTION

Tobacco use is the leading preventable cause of death in the United States and is disproportionately higher among veterans than nonveterans. We examined the prevalence of nicotine dependence and its associated risk factors among veterans who used health services in the US Department of Veterans Affairs (VA) system.

METHODS

Using a case-control design, we compared all VA health service users in fiscal year 2008-2009 (N = 5,031,381) who received a nicotine dependence diagnosis with those who did not. Independent risk and protective factors associated with receiving a nicotine dependence diagnosis were identified using logistic regression analysis. We conducted subgroup analyses on 2 groups of particular policy concern: homeless veterans and veterans who served in Iraq and Afghanistan.

RESULTS

Among all recent VA health service users, 15% (n = 749,353) received a diagnosis of nicotine dependence. Substance abuse, other mental health diagnoses, and homelessness were identified as major risk factors. Veterans who served in Iraq and Afghanistan were not found to be at increased risk compared to veterans from other war eras. Major risk and protective factors within the subgroups of homeless veterans and veterans who served in Iraq and Afghanistan were broadly similar to those in the general VA population.

CONCLUSION

Given that other studies have found higher rates of nicotine dependence among veterans, this risk behavior may be underdiagnosed in VA medical records. Veterans who are homeless or have mental health or substance abuse problems are at highest risk and should be targeted for smoking prevention and cessation interventions. These results support, in principle, efforts to integrate smoking cessation programs with mental health and homeless services.

An online survey of tobacco use, intentions to quit, and cessation strategies among people living with bipolar disorder

OBJECTIVES

  Tobacco use is prevalent among people living with bipolar disorder. We examined tobacco use, attempts to quit, and tobacco-related attitudes and intentions among 685 individuals with bipolar disorder who smoked ≥ 100 cigarettes in their lifetime.

METHODS

  Data were collected online through the website of the Depression and Bipolar Support Alliance, a mood disorder peer-support network.

RESULTS

  The sample was 67% female, 67% aged 26 to 50, and 89% Caucasian; 87% were current smokers; 92% of current smokers smoked daily, averaging 19 cigarettes/day (SD=11). The sample began smoking at a mean age of 17 years (SD=6) and smoked a median of 7 years prior to bipolar disorder diagnosis. Among current smokers, 74% expressed a desire to quit; intent to quit smoking was unrelated to current mental health symptoms [χ(2) (3)=5.50, p=0.139]. Only 33% were advised to quit smoking by a mental health provider, 48% reported smoking to treat their mental illness, and 96% believed being mentally healthy was important for quitting. Ex-smokers (13% of sample) had not smoked for a median of 2.7 years; 48% quit 'cold turkey.' Most ex-smokers (64%) were in poor or fair mental health when they quit smoking. At the time of the survey, however, more ex-smokers described their mental health as in recovery than current smokers [57% versus 40%; χ(2) (3)=11.12, p=0.011].

CONCLUSIONS

  Most smokers living with bipolar disorder are interested in quitting. The Internet may be a useful cessation tool for recruiting and potentially treating smokers with bipolar disorder who face special challenges when trying to quit and rarely receive cessation treatment from their mental health providers.

A randomised controlled trial linking mental health inpatients to community smoking cessation supports: a study protocol

BACKGROUND

Mental health inpatients smoke at higher rates than the general population and are disproportionately affected by tobacco dependence. Despite the advent of smoke free policies within mental health hospitals, limited systems are in place to support a cessation attempt post hospitalisation, and international evidence suggests that most smokers return to pre-admission smoking levels following discharge. This protocol describes a randomised controlled trial that will test the feasibility, acceptability and efficacy of linking inpatient smoking care with ongoing community cessation support for smokers with a mental illness.

METHODS/DESIGN

This study will be conducted as a randomised controlled trial. 200 smokers with an acute mental illness will be recruited from a large inpatient mental health facility. Participants will complete a baseline survey and will be randomised to either a multimodal smoking cessation intervention or provided with hospital smoking care only. Randomisation will be stratified by diagnosis (psychotic, non-psychotic). Intervention participants will be provided with a brief motivational interview in the inpatient setting and options of ongoing smoking cessation support post discharge: nicotine replacement therapy (NRT); referral to Quitline; smoking cessation groups; and fortnightly telephone support. Outcome data, including cigarettes smoked per day, quit attempts, and self-reported 7-day point prevalence abstinence (validated by exhaled carbon monoxide), will be collected via blind interview at one week, two months, four months and six months post discharge. Process information will also be collected, including the use of cessation supports and cost of the intervention.

DISCUSSION

This study will provide comprehensive data on the potential of an integrated, multimodal smoking cessation intervention for persons with an acute mental illness, linking inpatient with community cessation support.

Smoking cessation and chronic pain: patient and pain medicine physician attitudes

Although previous studies suggest that the clinical setting of an interdisciplinary pain treatment program may provide an optimal environment to promote smoking cessation, currently available smoking cessation interventions may be less effective for adults with chronic pain due, in part, to unrecognized clinical factors related to chronic pain. The specific aim of this qualitative study was to solicit information from adult smokers with chronic pain participating in an interdisciplinary pain treatment program regarding their perceptions of how smoking affects pain symptoms, and how these beliefs, cognitions, and emotions may either impede or facilitate smoking cessation. Similar information was solicited from a group of pain specialty physicians. The study involved 18 smokers with chronic pain, and seven physicians. Patients reported that smoking was an important coping strategy for pain and distress, primarily by offering an opportunity for distraction and avoidance, respectively. The majority of patients using opioids reported that opioid consumption stimulated smoking. Important barriers were identified toward making a quit attempt during pain treatment including quitting smoking while making changes in opioid use, and perceived difficulty managing multiple treatment-related stressors. Several pain-related benefits of smoking cessation were identified by physicians, but important barriers to providing smoking cessation services were recognized including lack of time and knowledge about how to help patients quit smoking. The findings of this study identified several novel and important clinical factors that should be incorporated into a targeted smoking cessation intervention for adults with chronic pain.