Trauma-Focused Smoking Cessation for Smokers Exposed to the World Trade Center Disaster: A Randomized Clinical Trial

Tobacco use, trauma exposure and PTSD: a systematic review

Tobacco use remains one of the most significant preventable public health problems globally and is increasingly concentrated among vulnerable groups, including those with trauma exposure or diagnosed with PTSD. The goal of this systematic review was to update and extend previous reviews. Of the 7224 publications that met the initial criteria, 267 were included in the review. Summary topic areas include conceptual frameworks for the relation between trauma or PTSD and tobacco use; associations between trauma exposure or PTSD and tobacco use; number and type of trauma exposures and tobacco use; PTSD symptoms and tobacco use; Treatment-related studies; and the examination of causal relations. Evidence continues to indicate that individuals exposed to trauma or diagnosed with PTSD are more likely to use tobacco products, more nicotine dependent and less likely to abstain from tobacco even when provided evidence-based treatments than individuals without trauma. The most commonly cited causal association proposed was use of tobacco for self-regulation of negative affect associated with trauma. A small proportion of the studies addressed causality and mechanisms of action. Future work should incorporate methodological approaches and measures from which we can draw causal conclusions and mechanisms to support the development of viable therapeutic targets.

The World Trade Center Health Program: Smoking cessation

Cigarette smoking can cause and/or worsen a variety of health conditions. The U.S. Preventive Services Task Force (USPSTF) recommends that smoking cessation services be offered to all adults who currently smoke, and governmental and non-governmental professional organizations support providing these interventions to patients who smoke. The World Trade Center (WTC) Health Program, a federal program that provides health monitoring and treatment to those directed exposed to the September 11, 2001 terrorist attacks, provides smoking cessation therapy for eligible members. This paper identifies treatment strategies for smoking cessation and references the treatment coverage policy in the WTC Health Program. In addition, this paper notes the higher smoking prevalence among those with mental health conditions such as posttraumatic stress disorder (PTSD), and the need for heightened cessation efforts given the lower quit success rates among such persons.

The prognostic utility of personality traits versus past psychiatric diagnoses: Predicting future mental health and functioning

Past psychiatric diagnoses are central to patient case formulation and prognosis. Recently, alternative classification models such as the Hierarchical Taxonomy of Psychopathology (HiTOP) proposed to assess traits to predict clinically-relevant outcomes. The current study directly compared personality traits and past diagnoses as predictors of future mental health and functioning in three independent, prospective samples. Regression analyses found that personality traits significantly predicted future first onsets of psychiatric disorders (ΔR2=06-.15), symptom chronicity (ΔR2=.03-.06), and functioning (ΔR2=.02-.07), beyond past and current psychiatric diagnoses. Conversely, past psychiatric diagnoses did not provide an incremental prediction of outcomes when personality traits and other concurrent predictors were already included in the model. Overall, personality traits predicted a variety of outcomes in diverse settings, beyond diagnoses. Past diagnoses were generally not informative about future outcomes when personality was considered. Together, these findings support the added value of personality traits assessment in case formulation, consistent with HiTOP model.

Impact of World Trade Center-Related Health Research: An Application of the NIEHS Translational Framework

The World Trade Center Health Program (WTCHP) has a research mission to identify physical and mental health conditions that may be related to the 9/11 terrorist attacks as well as effective diagnostic procedures and treatments for WTC-related health conditions. The ability of the WTCHP to serve its members and realize positive impacts on all of its stakeholders depends on effective translation of research findings. As part of an ongoing assessment of the translational impact of World Trade Center (WTC)-related research, we applied the National Institute of Environmental Health Sciences (NIEHS) translational framework to two case studies: WTC-related research on post-traumatic stress disorder (PTSD) and cancer. We conducted a review of 9/11 health-related research in the peer-reviewed literature through October 2017, grey literature, and WTCHP program documentation. We mapped peer-reviewed studies in the literature to the NIEHS framework and used WTCHP program documentation and grey literature to find evidence of translation of research into clinical practice and policy. Using the NIEHS framework, we identified numerous translational milestones and bridges, as well as areas of opportunity, within each case study. This application demonstrates the utility of the NIEHS framework for documenting progress toward public health impact and for setting future research goals.

Relationship of trauma exposure and PTSD to cigarette smoking prevalence, frequency, and quantity: Data from a nationally representative sample of U.S. adults

Individuals with Post-Traumatic Stress Disorder (PTSD) smoke cigarettes at much higher prevalences than the general population. Less is known about PTSD and other smoking behaviors (e.g., smoking quantity and frequency) or about smoking among individuals who experience trauma.

OBJECTIVE

To examine differences in cigarette smoking behaviors among adults in the United States (a) with no exposure to trauma or PTSD, (b) with trauma but no PTSD, and (c) with PTSD.

METHODS

Data came from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions-II (NESARC-II, 2004-2005) and included demographics, PTSD diagnoses, traumatic events, and smoking behaviors. Odds ratios and group differences in smoking prevalence and behaviors based on PTSD diagnoses and exposure to traumatic experiences were calculated.

RESULTS

Traumatic events and PTSD diagnoses were both associated with greater smoking prevalences than persons without trauma or PTSD. Individuals with PTSD who smoke were more likely to report daily smoking than those without PTSD who smoke (Cohen's d = 0.19). Cigarette users with either trauma or PTSD smoked more cigarettes per day than cigarette users without trauma or PTSD (Cohen's d = 0.35). US adults with trauma exposure or PTSD have higher smoking prevalences and more intense smoking behaviors than those without PTSD or trauma.

CONCLUSION

Trauma or PTSD may each serve as a clinical indicator of increased risk of cigarette smoking-related health problems and prompt the implementation of targeted interventions to reduce the harms of smoking. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Respiratory problems and anxiety sensitivity in smoking lapse among treatment seeking smokers

PURPOSE

The current study examined whether the interaction of lower respiratory symptoms and anxiety sensitivity is related to smoking lapse in the context of smoking cessation.

METHOD

Participants were adult daily smokers (N=60) exposed to the World Trade Center (WTC) disaster who were in a smoking cessation treatment program (75.0% male, 50.6years old [SD=9.2], and current smoking rate was 17.6 cigarettes per day (SD=10.6).

RESULTS

Results indicated that the interaction between lower respiratory symptoms and anxiety sensitivity was a significant predictor of greater risk for lapse (i.e., lower survival time; B=0.005, OR=1.01, p=0.039). Follow-up analysis showed that greater respiratory symptoms were a significant predictor of lapse risk among those with high (B=0.116, OR=1.12, p=0.025), but not those with low (B=-0.048, OR=0.95, p=0.322), levels of anxiety sensitivity.

DISCUSSION

The findings from the current study suggest that smokers with greater respiratory symptoms and higher levels of anxiety sensitivity may be associated with early lapse to smoking following smoking cessation treatment. Future work has the potential to inform the development of tailored cessation interventions for smokers who experience varying levels of lower respiratory symptoms and anxiety sensitivity.

Concurrent varenicline and prolonged exposure for patients with nicotine dependence and PTSD: A randomized controlled trial

BACKGROUND

Prevalence of smoking among individuals with posttraumatic stress disorder (PTSD) is disproportionately high, and PTSD is associated with especially poor response to smoking cessation treatment.

OBJECTIVE

The current study examined whether integrating treatments for smoking cessation (varenicline plus smoking cessation counseling; VARCC) and PTSD (prolonged exposure therapy; PE) enhances smoking outcomes among smokers diagnosed with PTSD.

METHOD

142 adults with nicotine dependence (ND) and PTSD were randomized to a treatment program consisting of varenicline, smoking cessation counseling, and PE (VARCC + PE) or to VARCC only. Seven-day point prevalence abstinence (PPA) at posttreatment (3-months postquit day) and follow-up (6-months postquit day), verified by serum cotinine levels and exhaled carbon monoxide, was the primary smoking outcome. Psychological outcomes were PTSD and depression severity. Mixed effects models included baseline PTSD severity as a moderator of treatment condition effects.

RESULTS

Overall, VARCC + PE participants did not show greater PPA than VARCC participants. However, treatment effects were moderated by baseline PTSD severity. For participants with moderate and high PTSD severity, VARCC + PE led to significantly higher PPA than VARCC alone (ps<.05). No differences between treatment conditions emerged for participants with low baseline PTSD severity. Participants who received PE showed significantly greater reduction of PTSD and depression symptoms than those who did not receive PE.

CONCLUSIONS

Integrating psychological treatment for PTSD and smoking cessation treatment enhances smoking cessation for participants with moderate or severe PTSD symptom severity, but does not enhance smoking cessation for participants with low baseline PTSD severity. (PsycINFO Database Record

Efficacy of smoking cessation therapy alone or integrated with prolonged exposure therapy for smokers with PTSD: Study protocol for a randomized controlled trial

Posttraumatic stress disorder (PTSD) is related to an increased risk of smoking cessation failure. In fact, the quit rate in smokers with PTSD (23.2%) is one of the lowest of all mental disorders. Features of PTSD that contribute to smokers' progression to nicotine dependence and cessation relapse include negative affect, fear, increased arousal, irritability, anger, distress intolerance, and anxiety sensitivity. Anxiety sensitivity is higher in people with PTSD than in any other anxiety disorder except for panic disorder. High anxiety sensitivity is uniquely associated with greater odds of lapse and relapse during quit attempts. Distress intolerance, a perceived or behavioral tendency to not tolerate distress, is related to both the maintenance of PTSD and problems in quitting smoking. Prolonged exposure (PE) and interoceptive exposure (IE) reduce PTSD symptoms, distress intolerance, and anxiety sensitivity. Thus, they emerge as promising candidates to augment standard smoking cessation interventions for individuals with PTSD. The present study tests a 12-session specialized treatment for smokers with PTSD. This Integrated PTSD and Smoking Treatment (IPST) combines cognitive-behavioral therapy and nicotine replacement treatment for smoking cessation (standard care; SC) with PE to target PTSD symptoms and IE to reduce anxiety sensitivity and distress intolerance. Adult smokers (N=80) with PTSD will be randomly assigned to either: (1) IPST or (2) SC. Primary outcomes are assessed at weeks 0, 6, 8, 10, 14, 16, 22, and 30.

Posttraumatic stress symptoms and body mass index among World Trade Center disaster-exposed smokers: A preliminary examination of the role of anxiety sensitivity

Among individuals exposed to the World Trade Center (WTC) disaster on September 11, 2001, posttraumatic stress disorder (PTSD) and symptoms are both common and associated with increased cigarette smoking and body mass. However, there is little information on the specific processes underlying the relationship of PTSD symptoms with body mass. The current study is an initial exploratory test of anxiety sensitivity, the fear of internal bodily sensations, as a possible mechanism linking PTSD symptom severity and body mass index (BMI). Participants were 147 adult daily smokers (34.0% female) exposed to the WTC disaster (via rescue/recovery work or direct witness). The direct and indirect associations between PTSD symptom severity and BMI via anxiety sensitivity (total score and subscales of physical, cognitive, and social concerns) were examined. PTSD symptom severity was related to BMI indirectly via anxiety sensitivity; this effect was specific to physical concerns about the meaning of bodily sensations. Interventions focusing on anxiety sensitivity reduction (specifically addressing physical concerns about bodily sensations) may be useful in addressing elevated BMI among trauma-exposed persons.