BACKGROUND/RATIONALE:
Cigarette smoking is the most lethal substance use disorder in terms of morbidity and mortality. While strides have been made to reduce smoking in military populations, smoking rates in Veterans remain high. Specialty clinic-based tobacco cessation programs have been shown to be efficacious in reducing smoking, but are infrequently attended limiting the impact on prevalence, disease impact, and economic costs of smoking. Attendance to specialty based smoking cessation clinics is as low as 6%-14%. Consequently, there is a need for smoking cessation models to be developed that will provide practical cost-effective interventions that increase the reach of existing evidenced based practices. The internet has the ability to improve reach of smoking cessation interventions by avoiding barriers that limit participation in highly efficacious specialty care.

OBJECTIVE(S):
The primary objective of this project was to compare the effectiveness of an internet-based smoking cessation intervention combined with a tele-health medication clinic for nicotine replacement therapy (NRT) to VA "usual care", i.e., referral to clinic based specialty care. Specific aims were to compare 1) rates of intervention reach as measured by the proportion of veterans who accessed care; 2) self-reported 7-day point prevalence abstinence rates at 3 months and 12 months post-randomization follow-ups; and 3) the relative cost-effectiveness of the web-based intervention to standard specialty care.

METHODS:
A total of 413 patients were proactively recruited from the Durham VA Medical Center and followed for 12 months. Current smokers were identified using electronic medical records and recruited through an introductory letter and telephone calls. Patients willing to make a quit attempt in the next 30 days were randomized to receive either a referral to VA specialty smoking cessation care (control) or to the internet intervention and tele-health medication clinic. Veterans with recent military service (i.e., OEF/OIF/OND Veterans) were purposely over-sampled. Participating Veterans completed baseline surveys that collected demographic data, smoking characteristics, key psychosocial variables, and screens for PTSD (PC-PTSD), depression (CES-D10), and alcohol misuse (AUDIT-C).

FINDINGS/RESULTS:
We enrolled 413 patients with a mean age of 43.2 years (SD=14.0), 51% were White, 15% were female, 54% were married, 82% had internet access at home, and 48% served during OEF/OIF/OND. Many participants screened positive for PTSD (40%), depression (43%), and alcohol abuse (29%). OEF/OIF/OND veteran smokers were significantly more likely to screen positive for a psychiatric condition and were less likely to be abstinent at 12 months than other era Veterans (11% vs. 18%).

Reach of the internet intervention was significantly greater as compared to the control. Fifty percent of those randomized to the internet arm registered on the web-based smoking cessation site while 19% of those randomized to specialty care attended any clinic based care. Patients randomized to the internet intervention were significantly more likely to use nicotine replacement therapy (NRT) than those randomized to specialty care; 76% versus 20%.

Analyses of the primary outcome (self-reported, 7-day point prevalence at the three month follow-up) were modeled using multiple imputation methods to account for missing data due to non-response and were adjusted for stratification variables which included gender and presence of psychiatric condition (i.e., presence of PTSD, depression, or alcohol abuse). At 3 months-post randomization, there were no significant differences in smoking cessation by arm; 17% (95% CI: 13%-23%) in the internet based intervention were abstinent compared to 12% (95% CI: 8% -17%) in the standard specialty care arm. Similarly, there were no differences between groups at the 12-month post-randomization follow up with 15% (95% CI: 10%-21%) of the internet arm reporting abstinence compared to 16% (95% CI: 12%-22%) of those referred to specialty care.

Among those randomized to usual care, any attendance at specialty care was significantly related to 3 month abstinence rates (23% vs. 10%). Among those randomized to the internet, registration alone was not related to quitting although total contact time with the site was significantly related to long term abstinence (r=.21). OEF/OIF/OND Veterans were significantly more likely to use the internet intervention compared to other Veterans (60% vs. 40%). Veterans who registered on the internet intervention returned to the site an average of 1 time (range = 1-5; mean = 0.77, s.d.=0.87; median=1). Forty-six Veterans (22%) did not use the site after they registered; 39% returned to the site once, and 8% returned to the site 2-5 times. On average, registered participants spent 33 minutes on the site (SD = 37.8; median = 35 minutes; interquartile range = 0-47 minutes). There was almost no use of many of the interactive expert systems and social support programs built into the site.

Cost and cost-effectiveness analyses were conducted from the perspective of the VA as payer and provider. Costs were significantly more for patients randomized to the internet arm where costs were $178 (SD= $135) versus only $27 (SD=$41) for those referred to specialty care. Of the $178 in costs for the internet participants, $120 was due to NRT costs; usual care participants incurred only $12 in NRT medications. These costs reflect that both penetration and intensity of NRT use was substantially higher among those in the internet intervention arm. The effectiveness measures in our analysis included life years gained and quality-adjusted life years (QALYs) based on the abstinence rates at 12 months. The internet intervention resulted in a gain of 0.51 life years, 0.62 undiscounted QALYS, and 0.26 discounted QALYs gained per patient. Usual care participants gained 0.47 life years, 0.59 undiscounted QALYS, and 0.26 discounted QALYs gained per patient. None of the effectiveness differences in means between the two groups achieved statistical significance.

IMPACT:
Smoking related diseases continue to exact a burden on the VA healthcare system. Current results suggest little benefit for a web-based and tele-health medication clinic approach compared to proactively identifying smokers and referring them to clinic based care. Despite increased reach compared to referral to clinic based smoking cessation care, there were no significant differences in comparative effectiveness between types of intervention. More intensive interventions that increase reach (e.g., proactive telephone counseling) may be needed in Veteran populations where the presence of psychiatric morbidity is high.

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External Links for this Project

NIH Reporter

Grant Number: I01HX000132-01
Link: https://reporter.nih.gov/project-details/7747730

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PUBLICATIONS:

Journal Articles

1. Calhoun PS, Datta S, Olsen M, Smith VA, Moore SD, Hair LP, Dedert EA, Kirby A, Dennis M, Beckham JC, Bastian LA. Comparative Effectiveness of an Internet-Based Smoking Cessation Intervention Versus Clinic-Based Specialty Care for Veterans. Journal of substance abuse treatment. 2016 Oct 1; 69:19-27. [view]
2. Bastian LA, Fish LJ, Gierisch JM, Stechuchak KM, Grambow SC, Keefe FJ. Impact of Smoking Cessation on Subsequent Pain Intensity Among Chronically Ill Veterans Enrolled in a Smoking Cessation Trial. Journal of pain and symptom management. 2015 Dec 1; 50(6):822-9. [view]
3. Zaborowski DE, Dedert EA, Straits-Troster K, Lee S, Wilson SM, Calhoun PS, Moore SD, Acheson S, Hamlett-Berry KW, Beckham JC. Public health clinical demonstration project for smoking cessation in American veterans who served since September 11, 2001. Journal of addiction medicine. 2011 Mar 1; 5(1):79-83. [view]
4. Calhoun PS, Wilson SM, Hicks TA, Thomas SP, Dedert EA, Hair LP, Bastian LA, Beckham JC. Racial and Sociodemographic Disparities in Internet Access and eHealth Intervention Utilization Among Veteran Smokers. Journal of racial and ethnic health disparities. 2016 Sep 15. [view]
5. Gierisch JM, Bastian LA, Calhoun PS, McDuffie JR, Williams JW. Smoking cessation interventions for patients with depression: a systematic review and meta-analysis. Journal of general internal medicine. 2012 Mar 1; 27(3):351-60. [view]
6. Calhoun PS, Levin HF, Dedert EA, Johnson Y, VA Mid-Atlantic Mental Illness Research, Education, Clinical Center Registry Workgroup, Beckham JC. The relationship between posttraumatic stress disorder and smoking outcome expectancies among U.S. military veterans who served since September 11, 2001. Journal of traumatic stress. 2011 Jun 1; 24(3):303-8. [view]
7. Gierisch JM, Straits-Tröster K, Calhoun PS, Beckham JC, Acheson S, Hamlett-Berry K. Tobacco use among Iraq- and Afghanistan-era veterans: a qualitative study of barriers, facilitators, and treatment preferences. Preventing chronic disease. 2012 Feb 16; 9:E58. [view]

Journal Other

1. Straits-Troster K, Acheson S, Beckham JC, Calhoun PS, Gierisch JM, Hamlett-Berry K. Tobacco use and cessation among returning combat veterans: A mixed methods study. [Abstract]. Behavioral medicine update : a publication of the Society of Behavioral Medicine. 2010 Apr 10; 39(S1). [view]

Conference Presentations

1. Gierisch JM, Bastian L, Calhoun PS, McDuffie J, Williams JW. A Systematic Review and Meta-Analysis of Smoking Cessation Interventions for Patients With Depression. Paper presented at: National Research Service Award Trainees Research Annual Conference; 2011 Jun 14; Seattle, WA. [view]
2. Calhoun PS, Levin-Apenson H, Campbell K, Zaborowski D, Dedert E, Dennis MF, Kirby A, Beckham JC. Assessment of mood, psychiatric symptoms and smoking relapse using ecological momentary assessment via electronic diaries in smokers with PTSD. Presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 16; Los Angeles, CA. [view]
3. Calhoun PS, Olsen MK, Smith V, Moore SD, Hair L, Datta SK, Beckham JC. Comparative Effectiveness of an Internet-Based Smoking Cessation Intervention versus Clinic-Based Specialty Care for Veterans. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA. [view]
4. Kirby A, Beckham JC, Carpenter HJ, Calhoun PS. Contingency management for smoking cessation in smokers with PTSD. Presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 16; Los Angeles, CA. [view]
5. Van Voorhees E, Dennis MF, McClernon JF, Calhoun PS, Wilson S, Johnson M, Beckham JC. DHEA(S), negative affect, and anxiety sensitivity in smokers with and without PTSD. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 16; Los Angeles, CA. [view]
6. Calhoun PS, Hill MR, Rohrer - Good L, Gierisch JM, Smith V, Grambow SC, Hamlett-Berry K, Beckham JC, Bastian L, Dutton C. Operation iQuit: Internet based smoking cessation and telemedicine to reduce smoking among U.S. OEF/OIF Veterans. Poster session presented at: International Society for Traumatic Stress Studies Annual Meeting; 2012 Nov 20; Baltimore, MD. [view]
7. Gierisch JM, Bastian L, Calhoun PS, McDuffie J, Williams JW. Smoking Cessation Treatments for Patients With Depression: A System Review of the Evidence. Paper presented at: AcademyHealth Annual Research Meeting; 2011 Jun 12; Seattle, WA. [view]

DRA: Substance Use Disorders, Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational, Prevention, Technology Development and Assessment
Keywords: Operation Enduring Freedom, Operation Iraqi Freedom, Smoking
MeSH Terms: none