Smoking cessation and care management for veterans with posttraumatic stress disorder: a study protocol for a randomized controlled trial

Influence of interaction between community health workers and adults with chronic diseases on risk mitigation through care coordination

Introduction

Addressing health disparities and barriers to care requires a comprehensive approach that involves participation of health care providers, multiple organizations, and service providers in the communities affected. Given the importance of using community health workers to help address the complex and overlapping medical, social, and behavioral needs of high-risk individuals, it is of utmost importance to understand their impact on health outcomes. This study examines how in-person interaction between community health workers and their clients influence the client's level of risk mitigation achieved through care coordination using the Pathways Community HUB model.

Methods

The study utilized two years of data extracted from the Care Coordination Systems database for 391 adults who participated in the Northwest Ohio Pathways Community HUB program. Using multinomial logistic regression analysis, we assessed how the interaction between community health workers and adults with chronic diseases who participated in the Northwest Ohio Pathways Community HUB program influenced the successful mitigation of their social, behavioral, and other medical risks over a 2-year period.

Results

Our findings show that as the number of in-person contacts between the community health worker and the client increased, the likelihood of completing all Pathways increased by 27% when compared to completing less than 50% of the assigned Pathways, after adjusting for potential confounders (odds ratio: 1.27, 95% confidence interval: 1.07−1.52).

Discussion

Using community health workers as part of care coordination teams may be effective in connecting communities to systems of care, helping individuals manage their health conditions and connecting individuals to needed social services. Their direct in-person interaction with at-risk individuals may increase the extent to which these individuals successfully address risks to their health and well-being.

The prevalence rate of smoking among Veterans: A forgotten epidemic

LAY SUMMARY

The purpose of this study was to learn more about the smoking habits of U.S. Veterans compared with the rest of the population and to find the best ways to help Veterans quit smoking. This study found that Veterans tend to smoke more than the general population and that some groups of Veterans smoke more than others. When helping Veterans to quit smoking, health care providers should use approaches that are based on evidence, such as cognitive behavioral therapy, cognitive processing therapy, mindfulness-based stress reduction, and biofeedback in addition to the traditional 3A cessation model (ask, advise, refer).

Real-time video counselling for smoking cessation

BACKGROUND

Real-time video communication software such as Skype and FaceTime transmits live video and audio over the Internet, allowing counsellors to provide support to help people quit smoking. There are more than four billion Internet users worldwide, and Internet users can download free video communication software, rendering a video counselling approach both feasible and scalable for helping people to quit smoking.

OBJECTIVES

To assess the effectiveness of real-time video counselling delivered individually or to a group in increasing smoking cessation, quit attempts, intervention adherence, satisfaction and therapeutic alliance, and to provide an economic evaluation regarding real-time video counselling.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, CENTRAL, MEDLINE, PubMed, PsycINFO and Embase to identify eligible studies on 13 August 2019. We searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov to identify ongoing trials registered by 13 August 2019. We checked the reference lists of included articles and contacted smoking cessation researchers for any additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), randomised trials, cluster RCTs or cluster randomised trials of real-time video counselling for current tobacco smokers from any setting that measured smoking cessation at least six months following baseline. The real-time video counselling intervention could be compared with a no intervention control group or another smoking cessation intervention, or both.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data from included trials, assessed the risk of bias and rated the certainty of the evidence using the GRADE approach. We performed a random-effects meta-analysis for the primary outcome of smoking cessation, using the most stringent measure of smoking cessation measured at the longest follow-up. Analysis was based on the intention-to-treat principle. We considered participants with missing data at follow-up for the primary outcome of smoking cessation to be smokers.

MAIN RESULTS

We included two randomised trials with 615 participants. Both studies delivered real-time video counselling for smoking cessation individually, compared with telephone counselling. We judged one study at unclear risk of bias and one study at high risk of bias. There was no statistically significant treatment effect for smoking cessation (using the strictest definition and longest follow-up) across the two included studies when real-time video counselling was compared to telephone counselling (risk ratio (RR) 2.15, 95% confidence interval (CI) 0.38 to 12.04; 2 studies, 608 participants; I2 = 66%). We judged the overall certainty of the evidence for smoking cessation as very low due to methodological limitations, imprecision in the effect estimate reflected by the wide 95% CIs and inconsistency of cessation rates. There were no significant differences between real-time video counselling and telephone counselling reported for number of quit attempts among people who continued to smoke (mean difference (MD) 0.50, 95% CI -0.60 to 1.60; 1 study, 499 participants), mean number of counselling sessions completed (MD -0.20, 95% CI -0.45 to 0.05; 1 study, 566 participants), completion of all sessions (RR 1.13, 95% CI 0.71 to 1.79; 1 study, 43 participants) or therapeutic alliance (MD 1.13, 95% CI -0.24 to 2.50; 1 study, 398 participants). Participants in the video counselling arm were more likely than their telephone counselling counterparts to recommend the programme to a friend or family member (RR 1.06, 95% CI 1.01 to 1.11; 1 study, 398 participants); however, there were no between-group differences on satisfaction score (MD 0.70, 95% CI -1.16 to 2.56; 1 study, 29 participants).

AUTHORS' CONCLUSIONS

There is very little evidence about the effectiveness of real-time video counselling for smoking cessation. The existing research does not suggest a difference between video counselling and telephone counselling for assisting people to quit smoking. However, given the very low GRADE rating due to methodological limitations in the design, imprecision of the effect estimate and inconsistency of cessation rates, the smoking cessation results should be interpreted cautiously. High-quality randomised trials comparing real-time video counselling to telephone counselling are needed to increase the confidence of the effect estimate. Furthermore, there is currently no evidence comparing real-time video counselling to a control group. Such research is needed to determine whether video counselling increases smoking cessation.

Motivational interviewing for smoking cessation

BACKGROUND

Motivational Interviewing (MI) is a directive patient-centred style of counselling, designed to help people to explore and resolve ambivalence about behaviour change. It was developed as a treatment for alcohol abuse, but may help people to a make a successful attempt to stop smoking.

OBJECTIVES

To evaluate the efficacy of MI for smoking cessation compared with no treatment, in addition to another form of smoking cessation treatment, and compared with other types of smoking cessation treatment. We also investigated whether more intensive MI is more effective than less intensive MI for smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register for studies using the term motivat* NEAR2 (interview* OR enhanc* OR session* OR counsel* OR practi* OR behav*) in the title or abstract, or motivation* as a keyword. We also searched trial registries to identify unpublished studies. Date of the most recent search: August 2018.

SELECTION CRITERIA

Randomised controlled trials in which MI or its variants were offered to smokers to assist smoking cessation. We excluded trials that did not assess cessation as an outcome, with follow-up less than six months, and with additional non-MI intervention components not matched between arms. We excluded trials in pregnant women as these are covered elsewhere.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RR) and 95% confidence intervals (CI) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta-analyses where appropriate, using Mantel-Haenszel random-effects models. We extracted data on mental health outcomes and quality of life and summarised these narratively.

MAIN RESULTS

We identified 37 eligible studies involving over 15,000 participants who smoked tobacco. The majority of studies recruited participants with particular characteristics, often from groups of people who are less likely to seek support to stop smoking than the general population. Although a few studies recruited participants who intended to stop smoking soon or had no intentions to quit, most recruited a population without regard to their intention to quit. MI was conducted in one to 12 sessions, with the total duration of MI ranging from five to 315 minutes across studies. We judged four of the 37 studies to be at low risk of bias, and 11 to be at high risk, but restricting the analysis only to those studies at low or unclear risk did not significantly alter results, apart from in one case - our analysis comparing higher to lower intensity MI.We found low-certainty evidence, limited by risk of bias and imprecision, comparing the effect of MI to no treatment for smoking cessation (RR = 0.84, 95% CI 0.63 to 1.12; I2 = 0%; adjusted N = 684). One study was excluded from this analysis as the participants recruited (incarcerated men) were not comparable to the other participants included in the analysis, resulting in substantial statistical heterogeneity when all studies were pooled (I2 = 87%). Enhancing existing smoking cessation support with additional MI, compared with existing support alone, gave an RR of 1.07 (95% CI 0.85 to 1.36; adjusted N = 4167; I2 = 47%), and MI compared with other forms of smoking cessation support gave an RR of 1.24 (95% CI 0.91 to 1.69; I2 = 54%; N = 5192). We judged both of these estimates to be of low certainty due to heterogeneity and imprecision. Low-certainty evidence detected a benefit of higher intensity MI when compared with lower intensity MI (RR 1.23, 95% CI 1.11 to 1.37; adjusted N = 5620; I2 = 0%). The evidence was limited because three of the five studies in this comparison were at risk of bias. Excluding them gave an RR of 1.00 (95% CI 0.65 to 1.54; I2 = n/a; N = 482), changing the interpretation of the results.Mental health and quality of life outcomes were reported in only one study, providing little evidence on whether MI improves mental well-being.

AUTHORS' CONCLUSIONS

There is insufficient evidence to show whether or not MI helps people to stop smoking compared with no intervention, as an addition to other types of behavioural support for smoking cessation, or compared with other types of behavioural support for smoking cessation. It is also unclear whether more intensive MI is more effective than less intensive MI. All estimates of treatment effect were of low certainty because of concerns about bias in the trials, imprecision and inconsistency. Consequently, future trials are likely to change these conclusions. There is almost no evidence on whether MI for smoking cessation improves mental well-being.

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of telephone support to help smokers quit, including proactive or reactive counselling, or the provision of other information to smokers calling a helpline.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2018.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which offered proactive or reactive telephone counselling to smokers to assist smoking cessation.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We pooled studies using a random-effects model and assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I2 statistic. In trials including smokers who did not call a quitline, we used meta-regression to investigate moderation of the effect of telephone counselling by the planned number of calls in the intervention, trial selection of participants that were motivated to quit, and the baseline support provided together with telephone counselling (either self-help only, brief face-to-face intervention, pharmacotherapy, or financial incentives).

MAIN RESULTS

We identified 104 trials including 111,653 participants that met the inclusion criteria. Participants were mostly adult smokers from the general population, but some studies included teenagers, pregnant women, and people with long-term or mental health conditions. Most trials (58.7%) were at high risk of bias, while 30.8% were at unclear risk, and only 11.5% were at low risk of bias for all domains assessed. Most studies (100/104) assessed proactive telephone counselling, as opposed to reactive forms.Among trials including smokers who contacted helplines (32,484 participants), quit rates were higher for smokers receiving multiple sessions of proactive counselling (risk ratio (RR) 1.38, 95% confidence interval (CI) 1.19 to 1.61; 14 trials, 32,484 participants; I2 = 72%) compared with a control condition providing self-help materials or brief counselling in a single call. Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate.In studies that recruited smokers who did not call a helpline, the provision of telephone counselling increased quit rates (RR 1.25, 95% CI 1.15 to 1.35; 65 trials, 41,233 participants; I2 = 52%). Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate. In subgroup analysis, we found no evidence that the effect of telephone counselling depended upon whether or not other interventions were provided (P = 0.21), no evidence that more intensive support was more effective than less intensive (P = 0.43), or that the effect of telephone support depended upon whether or not people were actively trying to quit smoking (P = 0.32). However, in meta-regression, telephone counselling was associated with greater effectiveness when provided as an adjunct to self-help written support (P < 0.01), or to a brief intervention from a health professional (P = 0.02); telephone counselling was less effective when provided as an adjunct to more intensive counselling. Further, telephone support was more effective for people who were motivated to try to quit smoking (P = 0.02). The findings from three additional trials of smokers who had not proactively called a helpline but were offered telephone counselling, found quit rates were higher in those offered three to five telephone calls compared to those offered just one call (RR 1.27, 95% CI 1.12 to 1.44; 2602 participants; I2 = 0%).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that proactive telephone counselling aids smokers who seek help from quitlines, and moderate-certainty evidence that proactive telephone counselling increases quit rates in smokers in other settings. There is currently insufficient evidence to assess potential variations in effect from differences in the number of contacts, type or timing of telephone counselling, or when telephone counselling is provided as an adjunct to other smoking cessation therapies. Evidence was inconclusive on the effect of reactive telephone counselling, due to a limited number studies, which reflects the difficulty of studying this intervention.

Posttraumatic stress disorder and cigarette smoking: A systematic review

BACKGROUND

Previous reviews of the PTSD and cigarette smoking literature showed high PTSD-smoking comorbidity and problematic smoking outcomes (Feldner et al., 2007, Clinical Psychology Review, 27, 14-45; Fu et al., 2007, Nicotine & Tobacco Research, 9, 1071-1084). However, past reviews also noted several prominent gaps in the literature, including a lack of etiological work examining underlying mechanisms and research on specialized PTSD-smoking treatments. The present review summarizes an extensive body of research conducted since the previous reviews targeting these areas of need.

METHODS

Literature searches identified 66 empirical studies specific to smoking and PTSD.

RESULTS

Smokers were approximately twice more likely to have PTSD than nonsmokers in the general population, and individuals with PTSD were approximately twice as likely to be current smokers. Smokers with PTSD evidenced more negative affect, trauma history, and comorbid psychiatric history, as well as quit attempts and higher relapse rates. PTSD symptoms were associated with expectations that smoking would reduce negative affect, which, in turn, was associated with increased smoking rate and nicotine dependence. Male sex was associated with nicotine dependence and PTSD avoidance, while the relationship between PTSD and smoking relapse due to withdrawal was stronger in females. Specialized, integrated PTSD and smoking cessation treatments showed promise in increasing quit success relative to standard care in randomized trials.

CONCLUSIONS

Rates of PTSD-smoking co-occurrence remain high. Notable gains have been made in relevant epidemiological and etiological research, although more work is needed in trauma-specific subpopulations. Several promising specialized treatments for comorbid smoking-PTSD have been developed and empirically tested but require replication.

Perspectives on a Home Telehealth Care Management Program for Veterans With Posttraumatic Stress Disorder Who Smoke

BACKGROUND

Individuals with posttraumatic stress disorder (PTSD) have high rates of smoking and low quit rates. We conducted a qualitative evaluation of an integrated smoking cessation randomized controlled trial (RCT) that used home telehealth and motivational interviewing (MI) to change smoking behaviors among individuals with PTSD.

METHOD

Using a convenience sample sourced from the original RCT, intervention and control group participants were invited to participate in a qualitative evaluation. Semistructured interview guides were used to assess the effectiveness of study components, make recommendations for future interventions, and identify facilitators/barriers to smoking cessation. We analyzed these data using an inductive and deductive, team-based content analysis approach.

RESULTS

We interviewed 32 study participants (intervention: n = 15, control: n = 17) who completed the original RCT within the previous 6 months. Respondents were highly satisfied with home telehealth and MI counseling. The intervention group respondents found MI counseling to be supportive, nonjudgmental, and informative. Control group respondents felt that they had received smoking cessation assistance. Respondents from both groups desired more information about PTSD and smoking, relied on smoking as a coping mechanism for PTSD, and believed that quitting was an individual choice.

CONCLUSION

Respondents reported that home telehealth and MI were acceptable ways to provide smoking cessation assistance to individuals with PTSD. The support and increased awareness of smoking behaviors were perceived as helpful. Future investigations should focus on increasing support and information about stress management, smoking, PTSD, and the relationship between them for individuals with PTSD who smoke.