BACKGROUND/RATIONALE:
Veterans with Posttraumatic Stress Disorder (PTSD) have high rates of smoking and have lower quit rates than other Americans. Since patients experience reductions in all-cause mortality when they quit smoking, even a small increase in quit rates can improve health and life expectancy. Motivation Interviewing (MI) has been shown to increase readiness to change. Care management using telehealth has been shown to improve access to care while reducing costs for veterans with chronic diseases. Nurses have successfully managed chronic diseases using telehealth by focusing on increasing self-management, positive behaviors and knowledge. Nurses are vital to increasing the level of support in the community through education and motivation and by responding to medical events in order to improve veterans' health. This study is unique as it integrated smoking cessation care into an already established and in-use telehealth system, allowing expanded access and facilitated implementation.

OBJECTIVE(S):
We hypothesized that integrated care management using telehealth and MI counseling plus usual care will (1) increase the proportion of patients who make self-reported quit attempts, progress in the stages of change and quit smoking when compared to usual care alone (2) increase Veterans' perception of care coordination and, for the intervention group, show high patient satisfaction regarding MI counseling and smoking cessation content, and (3) improve PTSD, depression, pain symptoms and quality of life. The qualitative interviews aim to gather in-depth understanding of the phenomena of participation and to obtain insights, from the perspective of the patients, about improving smoking cessation care and telehealth care management.

METHODS:
A prospective, single-blinded, single VA-site randomized trial evaluated the effectiveness of integrated smoking cessation care management using telehealth in addition to usual care (intervention group) with usual care (control group). All participants received the PTSD home telehealth program (usual care) during the intervention portion of the study. Additionally, the intervention group received (1) a 90-session written stage-based tobacco cessation curriculum based on MI principles and (2) weekly MI smoking cessation counseling. This protocol has IRB approval.

Inclusion criteria: Veterans with PTSD based on Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) criteria (diagnosis code 309.81) documented in their medical record, 18 years or older and were currently smoking one or more cigarettes per day at the time of recruitment. All eligible smokers were offered enrollment, regardless of their desire to quit smoking.

Exclusion criteria: Veterans who only used smokeless tobacco, pipes or cigars, had imminent risk of suicide or violence, had severe psychiatric symptoms or psychosocial instability likely to prevent participation in protocol (mental health or primary care provider will assess appropriateness), had clinically apparent, gross cognitive impairment, or were unable to connect to the telehealth appliance in their home.

Outcomes included 24 hour self-reported quit attempts, progression along the stages of change toward the action stage and sustained quit attempts, measured by bioverified 7-day point prevalence. Other outcomes included perception of care coordination, PTSD, depression, quality of life and pain symptoms, and satisfaction with MI intervention. All analyses were conducted using the intention to treat principle. We described baseline characteristics by study groups and test for differences in age, gender, co-morbidities including PTSD symptoms, depressive symptoms, suicide risk, chronic pain, cerebrovascular disease, lung cancer, esophageal cancers and other patient attributes. We are testing the primary hypothesis by comparing dichotomous variables, self-reported quit attempts as the outcome variable, at the completion of 90-sessions and at the end of the 6 month follow-up period between the two study arms. Then, to account for any imbalance in baseline characteristics and to improve the precision of estimates, we are testing the primary hypothesis using a logistic regression model and include baseline characteristics, tobacco dependence, other selected variables, and study group as independent variables.

Qualitative interviews were done with 32 study completers and were analyzed using an inductive process.

FINDINGS/RESULTS:
Enrollment ended in April 2013 and the final data were collected in May 2014. There were 178 individuals enrolled (three subjects were ineligible for study after consent) and 120 who completed the study (61 intervention and 59 control). Baseline characteristic were similar between intervention and control groups (n=175). Study groups are being compared in unadjusted analyses and multivariable models. We are in the process of analyzing the data comparing the proportion of patients who make self-reported quit attempts, progress along the stages of change and quit smoking between groups. We will submit the results for publication upon completion.

IMPACT:
Smoking continues to be a leading cause of preventable death. Veterans with PTSD who smoke face unique barriers and challenges in quitting smoking. This study directly addressed gaps in current care delivery by utilizing home telehealth and telephonic counseling to address tobacco cessation. We effectively and safely integrated tobacco cessation curricula into an in-use VA home telehealth system.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Battaglia C, Stein KF. A clinical translation of the research article titled "Building a tobacco cessation telehealth care management program for veterans with posttraumatic stress disorder". Journal of The American Psychiatric Nurses Association. 2013 Mar 1; 19(2):92-7. [view]
2. Battaglia C, Benson SL, Cook PF, Prochazka A. Building a tobacco cessation telehealth care management program for veterans with posttraumatic stress disorder. Journal of The American Psychiatric Nurses Association. 2013 Mar 1; 19(2):78-91. [view]

VA Cyberseminars

1. Battaglia C. Integrating Tobacco Cessation into a Home Telemonitoring System for Veterans with PTSD. [Cyberseminar]. 2014 Jul 15. [view]

Conference Presentations

1. Battaglia C. Testing the Feasibility and Fidelity of Telehealth Care Management and Smoking Cessation for Veterans with PTSD. Paper presented at: Society of General Internal Medicine Mountain West Regional Annual Meeting; 2009 Sep 11; Denver, CO. [view]
2. Benson S, Battaglia C, Cook P, Prochazka A. Testing the Feasibility and Fidelity of Telehealth Care Management and Smoking Cessation for Veterans with PTSD. Poster session presented at: University of Colorado National Primary Care Nurse Practitioner Symposium; 2010 Jul 15; Copper Mountain Resort, CO. [view]
3. Battaglia C, Benson S, Cook P, Prochazka A. Testing the Feasibility and Fidelity of Telehealth Care Management and Smoking Cessation for Veterans with PTSD. Poster session presented at: Society for Research on Nicotine and Tobacco Annual Conference; 2010 Feb 24; Baltimore, MD. [view]
4. Benson S, Battaglia C, Cook P, Prochazka A. Testing the Treatment Fidelity of a Behavioral Intervention (Motivational Interviewing) in a Feasibility Study of Telehealth Care Management and Tobacco Cessation for Veterans with Post Traumatic Stress Disorder (PTSD). Paper presented at: Rocky Mountain Regional Multidisciplinary Research and Evidence-Based Practice Annual Symposium; 2010 Mar 4; Denver, CO. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Substance Use Disorders, Health Systems
DRE: Treatment - Observational, Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Nursing, PTSD, Smoking
MeSH Terms: none