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Integration of Smoking Cessation into Mental Health Treatment for Veterans with PTSD

July 28, 2011: Cessation: Emerging Interventions and Innovations

Kim Hamlett-Berry, Ph.D., Director, Public Health Policy and Prevention, Office of Public Health, Department of Veteran's Affairs

There is a high prevalence of smoking in adults with psychiatric disorders and quit rates for this population are half the quit rate of smokers without such disorders. In particular, posttraumatic stress disorder (PTSD) is highly prevalent in the VHA patient population and is associated with a higher rate of smoking (31–61 percent). More veterans with PTSD are heavy smokers (48 percent) than those without PTSD and only 23 percent of smokers with PTSD report having quit smoking as compared to approximately 50 percent of all people who have ever smoked.

Barriers to effective tobacco dependence treatment among those with PTSD include: brief episodic care is not effective for a chronic and relapsing condition such as nicotine dependence; limited provider time does not allow for ongoing monitoring of smoking status and response to relapse; primary care providers do not have sufficient training in cessation treatment; limited time and training to address smoking is further complicated by PTSD; and providers often believe that patients with PTSD are not capable of quitting.

At the same time, the rationale for integrating smoking cessation treatment into mental health care for people with PTSD includes: providers have advanced training in treating behavioral and substance abuse disorders which readily translates into treatment of nicotine dependence; providers are well positioned to tailor cessation treatment to interactions between smoking and psychiatric symptoms; smoking can be treated within the context of an ongoing therapeutic relationship; and by including smoking cessation in mental health care access to evidence-based smoking cessation treatment for underserved veterans is increased.

Dr. Hamlett-Berry continued by describing the V.A.'s Integrated Smoking Cessation Care Learning Collaborative. A Learning Collaborative integrates best practices in training and consultation with quality improvement methods to help organizations rapidly implement and sustain evidence-based practices. The goals of the V.A. Learning Collaborative are that PTSD programs will: establish a system to identify smokers and track their tobacco use, readiness for smoking cessation, and treatments received; routinely inform smokers about the availability of integrated care and other cessation resources; ensure that staff who provide mental health treatment receive training in integrated care; ensure that staff who provide integrated care have access to supervision and/or consultation in the model; and regularly evaluate the use of integrated care.

The time period for the V.A. Integrated Smoking Cessation Collaborative is August 2010–September 2011. There have been challenges that include staffing changes and ensuring there are adequate prescribers who can assist with medications. Staff have also had concerns about whether smoking cessation should be their responsibility and some staff also hold the belief that people with PTSD either cannot quit or do not think that quitting smoking should be a priority.

Dr. Hamlett-Berry concluded with lessons learned: local clinical professionals are the champions in this effort; team-building is critical and takes time; allowing for local variations in implementation is a necessity; mental health leadership is critical for success; what gets measured, gets changed; and the benefits of a learning collaborative framework to help create and sustain system change are enormous. The V.A. Integrated Smoking Cessation Treatment Learning Collaborative has implications for other clinical settings including efforts to integrate smoking cessation in other mental health outpatient and residential PTSD clinical settings and in other substance use disorder settings. Work with partners in the Navy is currently underway.

Dr. Riley introduced the next panelist.

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