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


METHODS
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.


METHODS
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.


METHODS
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.


CONCLUSIONS
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.


BACKGROUND
clinicaltrials.gov Identifier: NCT00118534.
Veterans Affairs Puget Sound Health Care System, 1660 S Columbian Way, S-116 MHC, Seattle, WA 98108, USA. miles.mcfall@va.gov
Miles
M
McFall
Andrew J
AJ
Saxon
Carol A
CA
Malte
Bruce
B
Chow
Sara
S
Bailey
Dewleen G
DG
Baker
Jean C
JC
Beckham
Kathy D
KD
Boardman
Timothy P
TP
Carmody
Anne M
AM
Joseph
Mark W
MW
Smith
Mei-Chiung
MC
Shih
Ying
Y
Lu
Mark
M
Holodniy
Philip W
PW
Lavori
D003376:Counseling; D003863:Depression / Q000150:complications / Q000628:therapy; D005260:Female; D006801:Humans; D008297:Male; D008605:Mental Health Services / Q000458:organization & administration; D008875:Middle Aged; D012907:Smoking / Q000628:therapy*; D016540:Smoking Cessation; D013313:Stress Disorders, Post-Traumatic / Q000150:complications / Q000628:therapy*; D019966:Substance-Related Disorders / Q000628:therapy; D016896:Treatment Outcome; D014728:Veterans