Background: Research consistently indicates that individuals with psychiatric disorders smoke at rates substantially higher than those of the general population. In accord with evidence that the majority of smokers with psychiatric disorders express a desire to quit smoking, the VHA has been a national leader for integration of smoking-cessation services in health care settings, and increasingly is addressing tobacco use among veterans with psychiatric disorders. However, rates of treatment utilization by veteran smokers with psychiatric disorders are low. This is of particular concern as existing research with psychiatric populations indicates that treatment approaches found effective for the general population, including both behavioral and pharmacologic intervention, are also effective for smokers with psychiatric disorders. Although a majority of motivated smokers may attempt to quit on their own, putting smokers in contact with structured treatments will likely improve odds of success. As such, engaging smokers with psychiatric disorders in formal treatment for tobacco cessation is an issue of particular importance and relevance to VA. The current project is the first to develop an intervention specifically designed to enhance the utilization of smoking cessation treatment by veterans with psychiatric disorders.
Objectives:The objective of this research project was to develop a brief intervention delivered by telephone to facilitate engagement in evidence-based tobacco cessation treatment. Treatment development was informed by adaptation of an existing, in-person, protocol and incorporating qualitative evaluation of factors that promote or impede participation in tobacco cessation treatment by veterans with psychiatric disorders. The resulting intervention protocol and manual is being utilized in a pilot clinical trial.
Methods: This was a qualitative treatment development project utilizing a sequential design where information from successive phases was used to refine intervention content and delivery. Included were 26 cigarette smoking veterans with psychiatric disorders. Participants were primarily recruited from individuals referred for outpatient tobacco cessation treatment in the VA San Diego Healthcare System (VASDHS). We adapted a treatment engagement intervention developed for tobacco users hospitalized for depression. Adaptation of the treatment engagement intervention for telephone delivery was informed by a qualitative study. The initial phase of the study aimed to obtain veteran perceptions of factors that either facilitate or serve as obstacles to participating in tobacco cessation treatment. The original design was to conduct a series of focus groups. A qualitative interview script for was developed and refined over time based on input by the study investigators. It proved difficult to schedule focus groups at times that accommodated veterans, resulting in few participants attending each. We completed 5 focus groups with a total of 11 participants after which we switched to conducting individual qualitative interviews. We completed 11 individual interviews. Information from the qualitative interviews was utilized to adapt the existing treatment engagement intervention, yielding a pilot protocol and manual. The final phase of the study consisted of pilot implementation of the intervention along with telephone "callback" interviews to refine intervention content. Four pilot interviews were conducted, with feedback incorporated in the protocol after each callback interview. The final protocol and manual was produced with input from study investigators and our motivational interviewing consultant, with a focus on incorporating opportunities for the veteran to be heard and provide input during the course of the intervention.
Findings/Results: We successfully developed a veteran-centered smoking cessation treatment engagement intervention; the study yielded a protocol and manual for telephone delivery of the motivationally tailored intervention. Veteran feedback was critical in informing development of the protocol. Key findings were: 1) Veterans expressed concerns regarding feeling pressured to quit even if they weren't ready to do so; this feedback led to structuring the intervention with a more open and collaborative approach when contacting veterans (e.g., not assuming they were ready to quit, asking the smoker whether they planned on making any changes and highlighting their role in setting any change goals); 2) Veterans noted they at times felt like when they were contacted by the smoking cessation clinic the staff were reading from a script and were not interested in listening to them. In response we have incorporated client-centered motivational interviewing techniques throughout the protocol. This approach focuses on obtaining input, listening to the veterans, and using summaries and reflection to ensure that they know they are being heard. As such, discussion of treatment proceeds collaboratively rather than being prescriptive. After discussing their goals for change, assets and obstacles for engaging in smoking cessation, and motivations for change, veterans are briefly presented with an overview of available smoking cessation resources. Veterans are then asked if any of the treatment options seem like a good fit for them. If the veteran is unsure or the intervention selected does not seem like a good fit, permission is asked to provide advice, including a rationale (why the recommended approach might be appropriate for the veteran) and a recommended plan of action (when and where the veteran might engage in assistance for quitting smoking). These components of the treatment protocol were received positively by veterans participating in the pilot intervention sessions.
Impact: By developing a veteran-centered tobacco cessation treatment engagement intervention we anticipate increasing the proportion of cessation attempts by veterans with psychiatric disorders that will be supported by evidence-based treatment. Quit attempts supported by evidence-based treatment are expected to yield higher rates of cessation, thereby reducing associated negative consequences of cigarette smoking.
- Myers MG, Strong DR, Chen TC, Linke SE. Enhancing engagement in evidence-based tobacco cessation treatment for smokers with mental illness: A pilot randomized trial. Journal of substance abuse treatment. 2020 Apr 1; 111:29-36.