2023 HSR&D/QUERI National Conference

1117 — Smoking cessation among patients with chronic pain in a comparative effectiveness trial: Impact of depression

Lead/Presenter: Lori Bastian,  COIN - West Haven
All Authors: Bastian LA (West Haven COIN, VA Connecticut/Yale University), Driscoll MA(West Haven COIN, VA Connecticut/Yale University), Derycke EC(West Haven COIN, VA Connecticut), Edmond SN (West Haven COIN, VA Connecticut/Yale University), Mattocks KM (Northampton VA/University of Massachusetts), Goulet JL, (West Haven COIN, VA Connecticut/Yale University), Becker WC (West Haven COIN, VA Connecticut/Yale University)

Smoking cessation substantially decreases morbidity and mortality, yet more than half of patients with chronic pain continue to smoke, in part, because they report lacking skills to cope with pain and manage cravings. Depression, which is common among people with pain, is also a known barrier to smoking cessation, but little is known about how depression impacts smoking cessation in people with pain. The objective of this study was to test the comparative effectiveness of a telephone-delivered cognitive-behavioral intervention (CBI) that incorporates pain management against a standard smoking cessation intervention (STD) to promote smoking cessation among people with chronic pain and examine the impact of depression.

A randomized comparative effectiveness trial was conducted in two VA healthcare systems. Proactive recruitment (2017-2020) identified Veterans who reported current cigarette smoking, willingness to quit, and pain intensity of > = 4 on the 0-10 pain numerical rating scale for greater than 3 months. CBI included 5 telephone counseling sessions, a self-help manual, pedometer, and combination nicotine replacement therapy (nicotine patch, nicotine gum or lozenge; NRT). STD included a contact equivalent control that provided 5 telephone counseling sessions and combination NRT. Primary outcomes included prolonged (no smoking in the past 6 months) and point prevalence (no smoking for the past 7 and 30 days) abstinence at 6- and 12-month assessments. Secondary outcomes included a 30% reduction in pain interference at 6 and 12 months. The main moderator variable was depression (> = 10 on PHQ-9).

Veterans who smoke and have chronic pain were randomly allocated to CBI (n = 189) and STD (n = 182) and stratified by gender. At baseline, the 371 patients (88% men, median age = 60 years) smoked a median of 15 cigarettes per day for a median of 40 years and reported moderate past week pain intensity (5.2 (SD) = 1.6). Approximately 59% reported depression. Overall, subjects in the CBI arm reported higher 7-day (17% vs 14%, p = 0.39 at 6 months and 18% vs. 12%, p = 0.11 at 12 months) and 30-day (12% vs 6%, p = 0.04 at 6 months and 13% vs. 10%, p = 0.31 at 12 months) point prevalence abstinence compared to STD. At 6 months, CBI patients reported higher rates of clinically meaningful improvement in pain interference (34% vs. 19%, p = 0.01). Smoking cessation rates and pain interference were attenuated at 12 months. Moderation analyses revealed that those without depression had higher 30-day abstinence and 30% reduction in pain interference at 6 months in the CBI versus STD arms (17% vs 6%, p = 0.03 and 44% vs 23%, p = 0.04, respectively); among those with depression no differences between the two interventions were observed.

An innovative intervention addressing smoking cessation for Veterans with chronic pain yielded improvement in pain interference and 30-day point prevalence at 6 months that was not sustained at 12 months. Improvements in main outcomes were most prominent in the group without depression.

Given the high burden of depression in this population, future interventions should consider targeting co-occurring depression to optimize treatment and sustain improvements in smoking cessation rates and pain.