Research ArticleProactive Tobacco Treatment for Smokers Using Veterans Administration Mental Health Clinics
Introduction
Smoking remains the leading preventable cause of death in the U.S.1 People with a mental health diagnosis have particularly high rates of tobacco use and consume 40% of cigarettes sold in the U.S. annually.2 Most mental health patients who smoke are interested in quitting, but face a number of unique barriers that increase the difficulty of quitting—namely higher nicotine dependency, use of smoking for symptom management, higher levels of stress, and greater susceptibility to relapse.3, 4, 5, 6, 7, 8 Previous research has found that that intensive, multisession telephone counseling combined with cessation medications improves quit rates in smokers with mental health conditions.9
However, even when evidence-based treatments exist, mental health patients face barriers to accessing treatment including limited support and tobacco treatment from providers.8, 10, 11, 12, 13 In the U.S., outpatient psychiatrists have been screening their patients for smoking at declining rates, counsel or refer only about 20% of patients they know to be smokers to treatment, and provide cessation medications to only 1% of smokers.12 In a prior study that implemented a telephone care coordination program for smokers using Veterans Administration (VA) mental health services,9 mental health clinic providers could refer their patients to the program using an easy consult in the electronic medical record (EMR). Despite this easy referral mechanism, most providers made no referrals, and among those who did, 45% referred only one patient.
Prior research has found that providing tobacco treatment proactively (i.e., without relying on provider referral) increases population-level abstinence in primary care and socioeconomically disadvantaged populations.14, 15 There have been no previous trials testing this approach in a mental health population. The current study tests the reach and effectiveness of a proactive, intensive tobacco intervention for smokers using VA mental health services.16 It is hypothesized that the proactive intervention will increase the proportion of smokers who are abstinent at 12-month follow-up compared with usual VA care.
Section snippets
Study Population
The study was conducted from 2013 to 2017. The study used a two-group RCT design at four VA facilities: (1) the VA New York Harbor Healthcare System in New York City; (2) the VA Minneapolis Healthcare System in Minneapolis, Minnesota; (3) the Michael E. DeBakey VA Medical Center in Houston, Texas; and (4) the James A. Haley Veterans’ Hospital in Tampa, Florida. The research activities were approved by the VA Central IRB (protocol 12-42). The study was registered at clinicaltrials.gov
Results
Figure 1 displays the results of the study’s proactive recruitment. Of the 14,440 patients to whom an outreach packet was mailed, 2,395 (17%) returned a survey. Two percent (257) of mailings were undeliverable (bad address); 87 patients (1%) contacted the study to request no further contact; and 13 patients (0.1%) were reported by friends or family to be deceased. Study staff had no information about the nonresponse of 81% of patients to whom a packet was mailed. Of the patients who returned a
Discussion
This study was the first to test a proactive tobacco treatment approach in smokers receiving mental health specialty care. This large RCT produced several important findings. First, the proactive tobacco treatment intervention led to significant increases in long-term abstinence compared with usual care. Almost 20% of all participants reported 7-day abstinence 1 year after enrolling. This occurred in a patient population with severe psychological distress and only moderate motivation to quit at
Conclusions
This study supports proactive tobacco treatment approaches for smokers receiving mental health specialty care. Future research should identify the optimal proactive cessation counseling dose for mental health patients and methods for increasing treatment engagement.
Acknowledgments
This study was funded by the Veterans Affairs Health Services Research & Development (IIR-11-291). The study is registered at www.clinicaltrials.gov (NCT01737281). The findings and conclusions are those of the authors and do not necessarily represent the official position of the Veterans Health Administration.
S.E. Sherman and S.S. Fu were Principal Investigators on the trial. E.S. Rogers was Co-Investigator and Project Director, with responsibility for overseeing the study procedures and
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