Tobacco use is the leading preventable cause of death in the United States and contributes up to 24% of all VA healthcare costs. Veterans enrolled in the VA healthcare system smoke substantially more than the general population, which is particularly true among Veterans diagnosed with mental illness. Patients with bipolar disorder or schizophrenia have the highest smoking rates (69% and 58-90%, respectively) followed by those with PTSD (45-63%) and depression (31-51%). Numerous barriers exist for tobacco cessation among mental health patients, including high nicotine dependency, low rates of follow through for referrals, and limited availability of tobacco treatment tailored to their needs.
Most medical care providers assess tobacco use and advise smokers to quit, but they have insufficient time to follow up with treatment, leading to low long-term quit rates. Mental health providers who often meet regularly with patients report that they find tobacco cessation outside the scope of their practice and infrequently assess tobacco use to refer smokers for treatment. These practice patterns have been very difficult to change even with intensive methods and across various settings and provider types.
We used the electronic medical record system to identify smokers receiving mental health care and proactively reached out to engage them in treatment in line with the following aims:
1. Compare the reach and efficacy of a proactive outreach telephone-based tobacco cessation (PRO) program for patients seen in mental health to usual care (UC) advice and referral to local VA and community tobacco cessation resources.
2. Model longitudinal associations between baseline sociodemographic, medical and mental health characteristics and abstinence at 6 and 12 months in the PRO and UC conditions.
3. Identify VA mental health patient perceptions, attitudes and beliefs regarding the decisions to use tobacco cessation services
We used the electronic medical record to identify N=14,440 patients across 4 VA healthcare facilities who had a clinical reminder code indicating current tobacco use in the past year and who had a mental health visit in the past 6 months. We sent each patient an introductory letter and baseline survey. Respondents (N=1938) were randomized in a 1:1 fashion to intervention or control. Control participants received VA usual care. Intervention participants received proactive telephone counseling and cessation medications. We assessed tobacco use at 6 and 12 months from enrollment. The primary outcome was 7-day abstinence at the 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.
We also conducted semi-structured interviews with a subset of patients who enrolled in the study but a) declined counseling or b) dropped out of counseling after 1-2 sessions, in order to analyze constructs related to tobacco treatment decision-making. We randomly selected 60 patients from the first sample population (declined counseling) and selected 42 patients from the second sample population (dropped out of counseling) and sent 102 outreach letters inviting them to participate in telephone interviews.
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), NRT (47% vs 35%, OR=1.63, 95%CI=1.31-2.03) or both counseling and NRT (16% vs 2%, OR=11.93, 95%CI=6.34-22.47). Intervention participants were more likely at 12 months 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<.05).
Proactive outreach is more effective than usual VA care at increasing treatment engagement and abstinence rates in mental health patients. This study added to the growing literature supporting proactive, population-based approaches to tobacco treatment by showing that such an approach is more effective than usual care at increasing treatment engagement and long-term abstinence in mental health patients. Health care systems and public health agencies should adopt population-based tobacco treatment for mental health patients in order to reduce tobacco-related morbidity and mortality in this vulnerable population.
- Rogers ES, Fu SS, Krebs P, Noorbaloochi S, Nugent SM, Gravely A, Sherman SE. Proactive Tobacco Treatment for Smokers Using Veterans Administration Mental Health Clinics. American journal of preventive medicine. 2018 May 1; 54(5):620-629.
- Hammett P, Fu SS, Lando HA, Owen G, Okuyemi KS. The association of military discharge variables with smoking status among homeless Veterans. Preventive medicine. 2015 Dec 1; 81:275-80.
- Rogers ES, Fu SS, Krebs P, Noorbaloochi S, Nugent SM, Rao R, Schlede C, Sherman SE. Proactive outreach for smokers using VHA mental health clinics: protocol for a patient-randomized clinical trial. BMC public health. 2014 Dec 17; 14(1):1294.