- Unintentional Consequences of FDA Warnings: Varenicline
This study examined the association between FDA drug safety communications and the use of varenicline (Chantix) – a prescription drug used to treat addiction to smoking. Investigators tracked varenicline and nicotine replacement therapy (NRT) prescribing and evaluated the potential consequences of decreased varenicline use on lost opportunities to assist patients with quitting smoking and health outcomes, including mortality. Within 12 months of FDA communications about a labeling change for varenicline, there was a 69% reduction in VA outpatient prescriptions and a 38% decrease in Medicaid prescriptions. Varenicline use reached its low point in VA in early 2014, when the number of unique quarterly users was 5,990, representing an 82% decline from the first quarter of 2008. In addition, from 2008 to 2018, NRT users in VA increased by 73%. One year after the 2016 publication of a study that showed no significant increase in psychiatric/behavioral effects with varenicline compared with NRT or placebo, quarterly varenicline use had increased by 43% in VA patients and by 26% in Medicaid patients. The number of VA patients who did not quit smoking due to decreased varenicline use was estimated to be 20,544, which likely was associated with negative health effects.
Date: September 4, 2019
- Preoperative Surgical Screening for Asymptomatic Bacteriuria is Not Beneficial
Strong evidence that preoperative screening for bacteria in the urine, and treatment with antibiotics if found to be positive, improves clinical outcomes is lacking. This study sought to measure the association between asymptomatic bacteriuria (ASB) and key postoperative infectious outcomes, including surgical-site infection (SSI) and UTI, and determine if directed antimicrobial therapy was associated with reduced rates of infection after major surgical procedures. Findings showed that routine screening of preoperative urine cultures before major cardiac, orthopedic, and vascular surgical procedures was a low-yield clinical practice. ASB was identified in 4% of urine cultures, and after adjustments for other factors associated with postoperative infections (age, American Society of Anesthesiologists physical status class, smoking status, demographics, and diabetes status), Veterans with or without ASB had similar chances of surgical site infection (2.4% vs 1.6%). Antibiotic treatment of asymptomatic patients with ASB did not lead to improvement in any measurable postoperative clinical outcome. The incidence of SSI, UTI, and positive wound and urine culture results were the same in patients who were treated as in those who were untreated. This study – the largest and most robust to date – provides strong evidence that preoperative screening is of little value and should be discontinued as routine clinical practice.
Date: December 12, 2018
- Effects of Cannabis among Adults with Chronic Pain
This systematic review assesses the efficacy of cannabis for treating chronic pain, and provides a broad overview of the short- and long-term physical and mental health effects of cannabis use in chronic pain and general patient populations. Overall, investigators found low-strength evidence that cannabis may improve pain in some patients with neuropathic pain and insufficient evidence to characterize the effects of cannabis on pain in patients with multiple sclerosis. Moderate-strength evidence suggests that light to moderate cannabis smoking does not adversely impact lung function over about 20 years, however, the limited evidence examining the effects of heavy use suggests a possible deleterious effect on lung function over time. There is a consistent association between cannabis use and the development of psychotic symptoms over the short and long term, and cannabis appears to be associated with at least small, short-term deleterious effects on cognition in active users.
Date: August 5, 2017
- Comparing Food Insecurity between Veterans and non-Veterans
This study examined the prevalence of food insecurity in an older male population. Findings showed that there was a significantly lower prevalence of food insecurity among male Veterans compared to non-Veterans (6% vs. 12%, respectively). Nevertheless, several factors predisposed male Veterans to a higher risk for being food insecure. Younger Veterans (aged 50-64) were more likely to be food insecure and had nearly three times the prevalence of food insecurity compared to Veterans aged 65+ (12% vs. 4%, respectively). Overall, having a psychiatric diagnosis, self-reporting symptoms consistent with clinical depression, smoking, and experiencing any difficulty with activities of daily living (ADLs) were all significantly associated with increased odds of being food insecure, even after adjustment for demographics, medical comorbidities, and economic status. As Veterans aged 50-64 are not yet eligible for Social Security benefits, this group in particular should be screened for food insecurity.
Date: March 23, 2017
- Gender and Smoking Impact Severity of Musculoskeletal Pain among OEF/OIF Veterans
This study sought to examine gender differences in the association between cigarette smoking and moderate to severe musculoskeletal pain in Veterans of the wars in Afghanistan and Iraq. Findings showed that both gender and current smoking status were significantly associated with increased odds of moderate to severe musculoskeletal pain. Male Veteran non-smokers were more likely than female Veteran non-smokers to report moderate to severe pain; however, there were no gender differences in moderate to severe pain among Veteran smokers. Relative to female non-smokers, female Veteran smokers had increased odds of reporting moderate to severe musculoskeletal pain.
Date: March 14, 2017
- OEF/OIF/OND Veterans that Currently Smoke More Likely to Receive Opioid Prescription than Non-Smokers
This study sought to determine if smoking status is associated with the receipt of opioids among OEF/OIF/OND Veterans – and to examine important covariates of smoking (i.e., current pain intensity, gender, and mental health diagnoses) and receipt of opioids. Findings showed that compared to non-smokers, OEF/OIF/OND Veterans who were current smokers were more likely to receive an opioid prescription, even after controlling for covariates including: pain intensity, age, gender, service-connection, substance use disorder, mood disorders, and anxiety disorders. Veterans who reported a higher current pain intensity and those with pain diagnoses also were more likely to receive an opioid prescription. Among this young cohort of Veterans (mean age=30 years), more than one-third (34%) reported moderate to severe current pain intensity within +/-30 days of smoking status, with approximately 8% receiving at least one opioid prescription.
Date: September 21, 2016
- Lung Cancer Screening Programs May Have Unintended Consequences on Beliefs about Smoking Cessation
This study aimed to learn from patients who were offered screening how the availability of screening influenced their motivations regarding smoking cessation. Findings showed that current smokers attached exaggerated personal benefits to lung cancer screening. Misperceptions about susceptibility to harms from tobacco can be reinforced and potentially exacerbated by screening due to existing cognitive biases about smoking and exaggerated beliefs in the value of early detection provided by lung cancer screening. Five themes emerged around types of misperceptions related to cessation associated with screening: 1) screening was valuable because everyone screened would be protected, 2) screening would show how much damage had been caused by an individual’s smoking, 3) identification and monitoring of a lung nodule was evidence that cancer can be caught early (e.g., detection of a nodule meant that “screening was working”), 4) screening reduces the likelihood of needing cancer treatment (e.g., screening could cure cancer if the cancer was found early enough), and 5) screening verified the belief that smoking doesn’t harm everyone and “won’t harm me personally.”
Date: September 1, 2015
- Post-Menopausal Symptoms among Women Veterans with and without Type 2 Diabetes
This study sought to describe the postmenopausal symptom experience in women with type 2 diabetes – and to examine the association between glucose control and symptom severity. Findings showed that, despite higher BMI and increased comorbidities in women Veterans with diabetes compared to those without diabetes, the pattern of menopause symptoms did not differ by group. Symptom severity scores were highest for muscle and joint aches, followed by hot flashes and trouble sleeping, while headaches received the lowest severity scores. Measures of mental health (i.e., anxiety, depressed mood) were similar across groups. Among women Veterans with diabetes, worse glucose control, smoking, and a diagnosis of altered mood demonstrated a positive association with perceived menopause symptom severity, even after adjusting for other covariates. Women without diabetes were younger, of lower BMI, had fewer self-reported comorbid conditions, and reported better physical health.
Date: June 1, 2015
- Sleep Difficulties Associated with Risk Factors for Cardiovascular Disease among Younger Veterans and Active Duty Personnel
This study examined the relationship between sleep difficulties and several cardiovascular (CVD) risk factors (i.e., smoking status, body mass index, self-reported hypertension, hypertension medication use, clinic-based blood pressure readings, symptoms of depression and PTSD, and diagnosis of depression and PTSD) among relatively younger (mean age, 37 years) Veterans and active duty personnel of the Iraq and Afghanistan wars. Findings showed that 8% of the Veterans in this study endorsed only sleep onset difficulties, 9% endorsed only sleep maintenance difficulties, and 41% endorsed both sleep onset and sleep maintenance difficulties. Study participants with both sleep onset and maintenance difficulties had greater odds of being a current smoker, having a diagnosis of PTSD, having clinically significant PTSD symptoms, having a diagnosis of depression, and having clinically significant depression symptoms. The odds for these risk factors did not differ by race or age. Having the combination of sleep onset and maintenance difficulties also was associated with elevated systolic blood pressure readings and increased likelihood of reporting a hypertension diagnosis among younger white Veterans. Overall, study participants with sleep maintenance difficulties were older, while those having both sleep onset and maintenance difficulties were younger and reported more tours of duty. Veterans reporting sleep difficulties of any kind reported more symptoms of depression and PTSD. Authors note that since sleep difficulties are associated with several CVD risk factors, improving sleep in this younger population may reduce the progression of disease and avert the increased incidence of CVD found in older Veterans.
Date: March 27, 2015
- Proactive Tobacco Treatment More Successful than Usual Care among Veterans Attempting to Quit Smoking
This randomized controlled trial – the Veterans Victory over Tobacco Study – compared the effects of a proactive tobacco cessation care model versus a traditional cessation care model on the use of tobacco treatment and subsequent population-level smoking cessation rates. Findings showed that proactive tobacco cessation care that connected smokers to evidence-based telephone or in-person smoking cessation services is effective for increasing long-term, population-level cessation rates. The six-month prolonged smoking abstinence rate at one year was 14% for Veterans in the proactive care group, a significant increase compared to 11% for Veterans in the usual care group, and much higher than the 6% population-level cessation rate of the total US population. The proactive care group reported significantly higher rates of behavioral counseling combined with medication treatment compared to usual care (13% versus 5%). There was also a significant increase in receipt of a smoking cessation medication from VA providers among proactive care compared to usual care (35% versus 30%). About 85% of the usual care group and 83% of the proactive care group were daily smokers.
Date: March 10, 2014
- Women Veterans Report Poorer Health Outcomes Compared to Civilian and Active Duty Women
Veteran women reported consistently poorer health compared with other women, including poorer general health, greater likelihood of health risk behaviors (e.g., smoking), and greater likelihood of chronic conditions and mental health disorders. Veterans were most likely – and active duty least likely – to report frequent poor physical health. Veterans were more likely than civilian and active duty women to be obese or overweight – and to have cardiovascular disease. National Guard or Reserves (NG/R) women also were more likely to be overweight or obese than both civilian and active duty women. Veterans were more likely than civilians to report a history of depressive disorder and more likely than active duty women to report a history of anxiety disorder. NG/R women were more likely than civilian and active duty women to report both depression and anxiety. Tobacco use and lack of exercise were most commonly reported among Veterans and least commonly reported among active duty women. Compared to civilians, Veteran women were more highly educated and had higher incomes. Despite these protective factors, Veteran women reported faring better than civilians on only two indicators – health insurance and receiving clinical breast exams.
Date: May 1, 2012
- Perceived Discrimination Associated with Risk of Severe Coronary Obstruction among African American Veterans
Compared to white Veterans, African American Veterans with abnormal cardiac nuclear imaging studies had greater perceptions of racial discrimination that were related to increased risk for severe coronary obstruction – and to angiographic coronary obstruction, after controlling for clinical and psychosocial factors related to cardiovascular health. Based on their nuclear imaging studies, 44% of Veterans (both whites and African Americans) were at high risk for severe coronary obstruction. Among both African American and white Veterans, prior myocardial infarction (MI) and smoking were associated with high (vs. low/moderate) risk for severe coronary obstruction, while optimism was related to a decreased risk of severe obstruction. No significant associations between social support, negative affect, or religiosity and results from nuclear imaging or coronary angiography were found.
Date: April 1, 2012
- Veterans that Use Cigarette Smoking to Cope with Chronic Pain Experience Worse Pain-Related Outcomes
Veterans who reported smoking as a coping strategy for chronic pain scored significantly worse compared to Veterans who did not smoke and those who denied using cigarettes to cope with pain on the majority of measures of pain-related outcomes. After controlling for demographics and clinical factors, smoking as a coping strategy for pain was significantly and positively associated with pain intensity, pain interference, and fear of pain. There were no significant differences between the three groups on current symptoms of depression or anxiety, indicating that comorbid psychopathology likely did not contribute to poorer pain-related outcomes in the group who used cigarettes to cope with pain. The two smoking groups did not differ with respect to the frequency or severity of nicotine dependence, use of opioid medications, or on other clinical factors, suggesting that impairment in pain-related variables may be due to reliance on cigarettes as a coping strategy for chronic pain.
Date: March 1, 2012
- High Rates of CRC Screening among Veterans Receiving VA Care
This study examined colorectal cancer (CRC) testing rates in a national sample of Veterans to determine the modalities of CRC testing used and factors associated with the lack of fecal occult blood test (FOBT) card return. Findings showed that overall rates of CRC screening in the VA healthcare system were high (80%) among Veterans aged 51-75 years. This rate compares favorably with population estimates for the U.S., where only 60% of eligible Americans are estimated to have undergone a CRC screening test with either lower endoscopy or FOBT. Of Veterans who had received appropriate screening, the majority underwent colonoscopy in the prior 10 years (72%), followed by FOBT in the prior year (24%). A total of 31% of Veterans did not return FOBT cards that were provided. Factors associated with a lack of return included: younger age, non-Caucasian race, and current smoking. Secondary analyses in an augmented sample of women Veterans showed that findings were similar for both genders. As with men, smoking was associated with lack of FOBT return.
Date: September 16, 2011
- Adverse Post-Operative Events More Common among Current Veteran Smokers Compared with Prior or Non-Smokers
This study assessed the attributable risk and potential benefits of smoking cessation on surgical outcomes for Veterans who underwent non-cardiac, elective surgery in a VA hospital between 2002 and 2008. Findings showed that compared with both never and prior smokers – and controlling for patient and procedure risk factors – Veterans who were current smokers had significantly more post-operative pneumonia and surgical-site infection, despite being younger and having fewer comorbidities. Moreover, current smokers had increased odds of dying up to one year after surgery compared with prior smokers or Veterans who had never smoked. There was a dose-dependent increase in pulmonary complications based on pack-year exposure (one pack-year equals smoking 20 cigarettes a day for one year), with greater than 20 pack-years leading to a significant increase in smoking-related surgical complications. Previous literature suggests that pre-operative quit smoking interventions may reduce the risk of post-operative complications. Authors suggest that smoking cessation intervention be considered for Veterans who are current smokers, with greater than 20 pack-years of exposure, who undergo major surgical procedures.
Date: August 24, 2011
- VA Increases Prescriptions for Smoking Cessation Medications among Veterans
Since 2002, VA has implemented a range of policies and programs to increase evidence-based treatment for smoking. This study examined the change in rates of dispensing cessation-related medications to Veterans in the VA healthcare system to assess the impact of these policy changes. Findings show that VA policy initiatives instituted since 2002 have greatly increased prescriptions for smoking cessation medications among Veterans, while decreasing costs. The number of Veterans filling a prescription for nicotine replacement therapy (NRT) increased 63% from FY04 through FY08. Thirty-day-equivalent NRT prescriptions rose nearly 50% over the same period. Bupropion prescribing also rose sharply; the four-year growth rate among Veterans also prescribed a NRT was 61% greater than the 35% growth rate among all Veterans receiving bupropion prescriptions. While prescriptions for NRT and bupropion rose, spending per treated patient fell by 39% for bupropion and by 24% across all NRT formats (e.g., patch, gum).
Date: September 24, 2010
- History of Depression Remains a Risk Factor for Heart Disease after Accounting for Other Contributing Factors among Twin Veterans
A history of depression remained a risk factor for incident heart disease even after adjusting for numerous covariates including: sociodemographics, co-occurring psychopathology, smoking, obesity, diabetes, hypertension, and social isolation. Moreover, twins with both high genetic and phenotypic expression of depression were at greatest risk of ischemic heart disease (IHD). Results also show that twins with hypertension and twins with diabetes were more likely to have IHD, as were twins who reported no social support. Age, race, education, and marital status were not associated with IHD status.
Date: May 1, 2010
- Article Helps Identify Patients Prone to Persistent and Disabling Low Back Pain
Findings show that the most helpful components for predicting persistent, disabling low back pain were maladaptive pain coping behaviors (e.g., avoidance of work), nonorganic signs (e.g., suggests strong psychological component of pain), functional impairment, general health status, and presence of psychiatric comorbidities. In addition, baseline functional impairment showed an increasing likelihood of poor outcomes at three to six months and at one year. However, patients’ age, sex, education level, smoking status, and overweight status consistently failed to predict worse outcomes.
Date: April 7, 2010
- Veterans with Psychosis More Likely to Die from Heart Disease
This study assessed whether Veterans with mental disorders receiving care in the VA healthcare system were more likely to die from heart disease than Veterans without these disorders, and whether modifiable factors may explain mortality risks. Findings show that compared to Veterans without a mental health diagnosis, Veterans with psychosis (schizophrenia or other psychotic disorder diagnoses) were more likely to die from heart disease. Smoking and physical inactivity were the behavioral factors most strongly associated with mortality related to heart disease. Veterans with schizophrenia were the most likely to be current smokers, and those with bipolar disorder were the least likely to report adequate physical activity. Controlling for behavioral factors (e.g., smoking and physical inactivity) diminished but did not eliminate the impact of psychosis on mortality. The authors suggest that to reduce mortality related to heart disease, early interventions that promote smoking cessation and physical activity among Veterans with psychotic disorders are warranted.
Date: November 1, 2009
- Smoking Cessation Services for Veterans in VA Psychiatric Facility
This study had two goals: 1) determine staff characteristics that are associated with attitudes about providing smoking cessation services to Veterans who are psychiatric patients, and 2) seek suggestions from staff about what would be important to include in a tobacco cessation program. Findings show that nearly 75% of staff in this study thought that VA should do more to assist Veterans to quit smoking, yet only about 25% said that they personally provide cessation services. However, more than 50% felt moderately, very, or extremely confident in providing cessation services. Interestingly, nurses were less likely than other staff to feel that it was important to provide cessation services, which could be because of competing job demands. The most common reasons given by all respondents for not providing services were not enough time and lack of training. When asked how VA could best assist smokers to quit, most responses focused on educating Veterans about tobacco use and how they can quit, as well as providing tobacco cessation medications.
Date: June 1, 2009
- Cardiovascular Risk Reduction Clinic for Veterans with Diabetes
The Cardiovascular Risk Reduction Clinic (CRRC) is a pharmacist-coordinated clinic at the Providence VAMC designed to treat the four traditional cardiovascular risk factors (diabetes, dyslipidemia, hypertension, and smoking) to attain goals set forth by national guidelines for patients with diabetes or documented cardiovascular disease. Veterans are discharged from the CRRC when guideline-recommended goals for hemoglobin A1c, low-density lipoprotein cholesterol, blood pressure, and smoking are achieved or mostly achieved. This study evaluated the maintenance of these goals for two to three years after discharge from the CRRC. Findings show that Veterans who completed the program maintained two goals – HbA1c and LDL-C – over three years of observation. The effect on blood pressure was less durable, with half of the Veterans who were at target levels at discharge from the CRRC reaching systolic BP >130 within six months after discharge. Results also show that the most important factor to consider for risk of failure after successful attainment of a cardiovascular goal is how poorly controlled the goal was at baseline.
Date: March 1, 2009
- Veterans with Spinal Cord Injury Report Frequent Physical and Mental Health Concerns
Overall, veterans with spinal cord injury (SCI) were much more likely to experience frequent physically and mentally unhealthy days, and frequent days with depression than what has been reported for the general population. In addition, both chronic illnesses and smoking had a substantial effect on health-related quality of life for persons with SCI.
Date: July 1, 2008