Research Article
Proactive Tobacco Treatment for Smokers Using Veterans Administration Mental Health Clinics

https://doi.org/10.1016/j.amepre.2018.02.011Get rights and content

Introduction

Veterans with a mental health diagnosis have high rates of tobacco use but encounter low rates of treatment from providers. This study tested whether a proactive tobacco treatment approach increases treatment engagement and abstinence rates in Department of Veterans Affairs mental health patients.

Study design

RCT.

Setting/participants

The study was performed from 2013 to 2017 and analyses were conducted in 2017. Investigators used the electronic medical record at four Veterans Administration facilities to identify patients documented as current smokers and who had a mental health clinic visit in the past 12 months.

Intervention

Patients were mailed an introductory letter and baseline survey. Survey respondents were enrolled and randomized to intervention (n=969) or control (n=969). Control participants received a list of usual Veterans Administration smoking services. Intervention participants received a motivational outreach call, multisession telephone counseling, and assistance with obtaining nicotine replacement therapy.

Main outcome measures

Participants completed surveys at baseline, 6 months, and 12 months after randomization. The primary outcome was self-reported 7-day abstinence from cigarettes at 12-month follow-up. Secondary outcomes included use of cessation treatment, self-reported 7-day abstinence at 6-month follow-up, and 6-month prolonged abstinence at 12-month follow-up.

Results

At 12 months, intervention participants were more likely to report using telephone counseling (19% vs 3%, OR=7.34, 95% CI=4.59, 11.74), nicotine replacement therapy (47% vs 35%, OR=1.63, 95% CI=1.31, 2.03), or both counseling and nicotine replacement therapy (16% vs 2%, OR=11.93, 95% CI=6.34, 22.47). Intervention participants were more likely to report 7-day abstinence (19% vs 14%, OR=1.50, 95% CI=1.12, 2.01) and prolonged 6-month abstinence (16% vs 9%, OR=1.87, 95% CI=1.34, 2.61). After adjusting for non-ignorable missingness at follow-up, the intervention effects on 7-day and prolonged abstinence remained significant (p<0.05).

Conclusions

Proactive outreach was more effective than usual Veterans Administration care at increasing treatment engagement and long-term abstinence in mental health patients.

Trial registration

This study is registered at www.clinicaltrials.gov NCT01737281.

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

References (34)

  • L. Twyman et al.

    Perceived barriers to smoking cessation in selected vulnerable groups: a systematic review of the qualitative and quantitative literature

    BMJ Open

    (2014)
  • A.N. Thorndike et al.

    U.S. physicians’ treatment of smoking in outpatients with psychiatric diagnoses

    Nicotine Tob Res

    (2001)
  • D.J. Cohen et al.

    Implementing health behavior change in primary care: lessons from prescription for health

    Ann Fam Med

    (2005)
  • E. Rogers et al.

    Tobacco use screening and treatment by outpatient psychiatrists before and after release of the American Psychiatric Association treatment guidelines for nicotine dependence

    Am J Public Health

    (2014)
  • K.P. Richter et al.

    Patients’ views on smoking cessation and tobacco harm reduction during drug treatment

    Nicotine Tob Res

    (2002)
  • S.S. Fu et al.

    Proactive tobacco treatment and population-level cessation: a pragmatic randomized clinical trial

    JAMA Intern Med

    (2014)
  • S.S. Fu et al.

    Proactive tobacco treatment offering free nicotine replacement therapy and telephone counselling for socioeconomically disadvantaged smokers: a randomised clinical trial

    Thorax

    (2016)
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