Treating Tobacco Treating Tobacco Treating Tobacco Treating Tobacco Dependence and Providing Dependence and Providing Dependence and Providing Dependence and Providing Smoking Cessation Services: Smoking Cessation Services: What Have We Learned? What Have We Learned? Mark D Ackerman Ph D Mark D Ackerman Ph D Mark D. Ackerman, Ph.D Mark D. Ackerman, Ph.D Director, Tobacco Director, Tobacco Dependence Treatment Dependence Treatment Program Program VA Medical Center/Emory University School VA Medical Center/Emory University School of Medicine, Atlanta, Georgia of Medicine, Atlanta, Georgia
Transcript
Treating TobaccoTreating TobaccoTreating Tobacco Treating Tobacco Dependence and ProvidingDependence and ProvidingDependence and Providing Dependence and Providing
Smoking Cessation Services: Smoking Cessation Services: What Have We Learned?What Have We Learned?
Mark D Ackerman Ph DMark D Ackerman Ph DMark D. Ackerman, Ph.DMark D. Ackerman, Ph.DDirector, Tobacco Director, Tobacco
VA Medical Center/Emory University School VA Medical Center/Emory University School of Medicine, Atlanta, Georgiaof Medicine, Atlanta, Georgia
OBJECTIVESOBJECTIVESOBJECTIVESOBJECTIVES
Prevalence of tobacco use within VAPrevalence of tobacco use within VAPrevalence of tobacco use within VAPrevalence of tobacco use within VAHealth Consequences of tobacco useHealth Consequences of tobacco useP h l i t’ l l d ithiP h l i t’ l l d ithiPsychologist’s role as a leader within Psychologist’s role as a leader within behavior change and tobacco cessationbehavior change and tobacco cessationEvidenceEvidence--based treatment approaches to based treatment approaches to tobacco cessationtobacco cessationSpecial PopulationsSpecial Populations
PREVALENCEPREVALENCEPREVALENCEPREVALENCE
19 8%19 8% of Americans are currentof Americans are current smokerssmokers19.8% 19.8% of Americans are current of Americans are current smokerssmokers46 million adults are smokers46 million adults are smokersSmokingSmoking--attributable costs to society:attributable costs to society:
$96 billion per year medical expenses$96 billion per year medical expensesp y pp y p$97 billion lost productivity $97 billion lost productivity (CDC, 2007)(CDC, 2007)
USUS leading cause of premature deathleading cause of premature deathUS US leading cause of premature death leading cause of premature death at 443,000 at 443,000 deaths each deaths each year year (CDC, 2010)(CDC, 2010)
L di d th/di ithi VAL di d th/di ithi VALeading cause death/disease within VA Leading cause death/disease within VA
2008 Current Smokers in VA
Age 45-64y = 64% Income <36K = 63%Income <36K = 63%
2008 Survey of Veteran 2008 Survey of Veteran Enrollees (7.3 Million)Enrollees (7.3 Million)
70% of veterans (5 1 million) reported70% of veterans (5 1 million) reported70% of veterans (5.1 million) reported 70% of veterans (5.1 million) reported being an “ever” (current or former) smokerbeing an “ever” (current or former) smoker72% (3 7 million) reported: former smoker72% (3 7 million) reported: former smoker72% (3.7 million) reported: former smoker72% (3.7 million) reported: former smoker30% (2.1 million) reported: never smoker30% (2.1 million) reported: never smoker18% (1.3 million)reported: “recent quitter”18% (1.3 million)reported: “recent quitter”Current smokers make up 19.7% of the Current smokers make up 19.7% of the ppentire VA enrollee populationentire VA enrollee population
Prevalence of Smoking within Prevalence of Smoking within Chronic Veteran PopulationChronic Veteran Population
Veterans receiving chronic care likely Veterans receiving chronic care likely differ from veterans who responded to the differ from veterans who responded to the 2008 Survey2008 SurveyReason: Higher rates of psychiatric Reason: Higher rates of psychiatric g p yg p ydisorders, substance abuse and medical disorders, substance abuse and medical coco--morbidities;morbidities;;;Same factors associated with increased Same factors associated with increased smoking within nonsmoking within non--VA population;VA population;smoking within nonsmoking within non VA population; VA population;
Current Enrollee Smokers by Current Enrollee Smokers by VISNVISN
Highest % current smokers:Highest % current smokers:Highest % current smokers:Highest % current smokers:VISN 10: 24.8%VISN 10: 24.8%VISN 9: 24 3%VISN 9: 24 3%VISN 9: 24.3%VISN 9: 24.3%
Lowest % current smokers:Lowest % current smokers:VISN 3: 12.8%VISN 3: 12.8%VISN 4 and 1: 16.6% and 16.7%VISN 4 and 1: 16.6% and 16.7%S a d 6 6% a d 6 %S a d 6 6% a d 6 %
Largest reduction in current smokers:Largest reduction in current smokers:VISN 7: 19 7%VISN 7: 19 7%VISN 7: 19.7%VISN 7: 19.7%
Atlanta VA Medical CenterAtlanta VA Medical CenterDecatur GADecatur GADecatur, GADecatur, GA
SITES OF CARE AND SERVICES OFFEREDSITES OF CARE AND SERVICES OFFEREDThe The Atlanta VAMC has 405 authorized inpatient beds (273 hospital, 120 Atlanta VAMC has 405 authorized inpatient beds (273 hospital, 120 Community Living Center and 12 PRRTP) and is a tertiary care facility Community Living Center and 12 PRRTP) and is a tertiary care facility
classified as a Complexity Level 1A facility. It is a teaching hospital, providing a classified as a Complexity Level 1A facility. It is a teaching hospital, providing a full range of patient care services complete with statefull range of patient care services complete with state--ofof--thethe--art technology, art technology,
education and research Comprehensive health care is provided througheducation and research Comprehensive health care is provided througheducation and research. Comprehensive health care is provided through education and research. Comprehensive health care is provided through emergency medicine, primary care, tertiary care, and longemergency medicine, primary care, tertiary care, and long--term care in the term care in the
areas of medicine, surgery, mental health, physical medicine and rehabilitation, areas of medicine, surgery, mental health, physical medicine and rehabilitation, neurology, oncology, dentistry, geriatrics, and extended care. The Atlanta neurology, oncology, dentistry, geriatrics, and extended care. The Atlanta
VAMC is part of the VA Southeast Network (VISN 7), which includes facilities VAMC is part of the VA Southeast Network (VISN 7), which includes facilities in Georgia, Alabama, and South Carolina. The Atlanta VAMC Community in Georgia, Alabama, and South Carolina. The Atlanta VAMC Community
Li i C t t Atl t d i l d t d d h bilit tiLi i C t t Atl t d i l d t d d h bilit tiLiving Center serves metro Atlanta and includes extended care rehabilitation, Living Center serves metro Atlanta and includes extended care rehabilitation, psychopsycho--geriatric care, and general long term care. The facility also serves as a geriatric care, and general long term care. The facility also serves as a
prosthetics treatment center, fabricating and supplying mechanical devices prosthetics treatment center, fabricating and supplying mechanical devices such as artificial limbs for patients within the states of Georgia, South Carolina such as artificial limbs for patients within the states of Georgia, South Carolina
and Alabama. and Alabama.
Atlanta VA Tobacco Dependence Atlanta VA Tobacco Dependence T t t PT t t PTreatment ProgramTreatment Program
Designated as a “Program of Excellence” inDesignated as a “Program of Excellence” inDesignated as a Program of Excellence in Designated as a Program of Excellence in 2007;2007;FollowFollow--up telephone survey of 432 veteran up telephone survey of 432 veteran p p yp p yparticipants treated over a 15 month period participants treated over a 15 month period (2001(2001--2004) revealed:2004) revealed:Quit: 28.9% Smoking Less: 40.6%Quit: 28.9% Smoking Less: 40.6%Smoking Same: 28.9% or More: 1.6% Smoking Same: 28.9% or More: 1.6% Better group attendance = higher cessation Better group attendance = higher cessation (p=.002)(p=.002)
Georgia Psychological Association, May 2004
Atlanta VA Tobacco Dependence Atlanta VA Tobacco Dependence Treatment ProgramTreatment Program
20092009Total # veterans treated in group: 1586Total # veterans treated in group: 1586ggTotal Unique: 437Total Unique: 437First time group visits : 469First time group visits : 469First time group visits : 469First time group visits : 469FollowFollow--up group attendee visits: 1117up group attendee visits: 1117No Show Rate: 51%No Show Rate: 51%
Psychologists as LeadersPsychologists as LeadersPsychologists as LeadersPsychologists as Leaders
Behavior plays a primary role in health andBehavior plays a primary role in health andBehavior plays a primary role in health and Behavior plays a primary role in health and disease;disease;Smoking and tobacco use is a behaviorSmoking and tobacco use is a behaviorSmoking and tobacco use is a behavior, Smoking and tobacco use is a behavior, and is the leading cause of preventable and is the leading cause of preventable death and disease both within and outsidedeath and disease both within and outsidedeath and disease both within and outside death and disease both within and outside VA;VA;B i t f h l i t b h iB i t f h l i t b h iBy virtue of psychologists behavior By virtue of psychologists behavior change expertise, we should and do take change expertise, we should and do take l d iti i t b til d iti i t b tilead positions in tobacco cessation lead positions in tobacco cessation programs;programs;
VA Smoking VA Smoking and Tobacco Use and Tobacco Use Cessation Survey Cessation Survey by Disciplineby DisciplineTotal of 423 FTEE to SCP at 151 facilities:Total of 423 FTEE to SCP at 151 facilities:Total of 423 FTEE to SCP at 151 facilities:Total of 423 FTEE to SCP at 151 facilities:Discipline Leadership by Percent:Discipline Leadership by Percent:
P h l i t 22%P h l i t 22%Psychologist: 22%Psychologist: 22%Registered Nurse: 12%Registered Nurse: 12%Social Worker: 9%Social Worker: 9%Physician (MD/DO): 9%Physician (MD/DO): 9%Physician (MD/DO): 9%Physician (MD/DO): 9%Nurse Practitioner: 8%Nurse Practitioner: 8%PhPh D 6%D 6%PharmPharm D: 6%D: 6%
Smoking and Tobacco Use Cessation Survey, 2005Smoking and Tobacco Use Cessation Survey, 2005
Tobacco DependenceTobacco Dependenceas a Chronic Diseaseas a Chronic Disease
Tobacco DependenceTobacco Dependence
Physiological Psychological/Behavioraly g y g
The addiction to nicotine The habit of using tobacco
Treatment Treatment
The addiction to nicotine The habit of using tobacco
Medications for cessation Counseling & Behavioral Therapy
Treatment should address ALL aspects of dependence
IncreasesIncreases mesolimbicmesolimbic dopamine throughdopamine throughIncreases Increases mesolimbicmesolimbic dopamine through dopamine through actions at actions at nAChnACh receptorsreceptors
heart rateheart rate appetite or appetite or weight gain weight gain
Begins 1 6 hours after smoking cessationBegins 1 – 6 hours after smoking cessation
Peaks 24 – 48 hours
VA First LineVA First Line PharmacotherapiesPharmacotherapiesVA First Line VA First Line PharmacotherapiesPharmacotherapies
Nicotine PatchNicotine Patch
Nicotine GumNicotine Gum
Nicotine LozengeNicotine Lozenge
BupropionBupropion SRSR
Combination Therapy Combination Therapy
Tobacco Use Cessation Medications Tobacco Use Cessation Medications Available at VAAvailable at VAAvailable at VAAvailable at VA
DoseDose Adverse effectsAdverse effects
P t hP t h 21mg x 421mg x 4 6wks then 14mg x 26wks then 14mg x 2 3wks3wks Ski ti i iSki ti i iPatchPatch 21mg x 421mg x 4--6wks, then 14mg x 26wks, then 14mg x 2--3wks,3wks,then 7mg x 2then 7mg x 2--3wks; adjust dose based on 3wks; adjust dose based on withdrawal symptoms, urges, and comfortwithdrawal symptoms, urges, and comfort
GumGum 4mg (>20cigs/d) or 2mg (<20cigs/d) q14mg (>20cigs/d) or 2mg (<20cigs/d) q1--2hrs x 2hrs x Hiccups, dyspepsia, jaw Hiccups, dyspepsia, jaw GumGum g ( g ) g ( g ) qg ( g ) g ( g ) q6wks (usu 106wks (usu 10--12 pieces/d), then q212 pieces/d), then q2--4hrs x 34hrs x 3--
4wks, then q44wks, then q4--6hrs x 26hrs x 2--3wks; taper as tolerated3wks; taper as tolerated
ccups, dyspeps a, jaccups, dyspeps a, jaache, lightheadednessache, lightheadedness
LozengeLozenge 4mg lozenge q14mg lozenge q1--2hrs x 6wks (minimum of 2hrs x 6wks (minimum of 9/day) then 1 q29/day) then 1 q2 4hrs x 3wks then 1 q44hrs x 3wks then 1 q4 8hrs x8hrs x
Nausea, hiccups, Nausea, hiccups, d i hd i h9/day), then 1 q29/day), then 1 q2--4hrs x 3wks, then 1 q44hrs x 3wks, then 1 q4--8hrs x 8hrs x
3wks; taper as tolerated3wks; taper as tolerateddyspepsia, cough; dyspepsia, cough;
Frequency of AE’s related to Frequency of AE’s related to amount usedamount used
BupropionBupropion 150mg qd x 3d then 150mg bid x 4d then STOP150mg qd x 3d then 150mg bid x 4d then STOP Insomnia, dry mouth;Insomnia, dry mouth;Bupropion Bupropion SR SR
150mg qd x 3d then 150mg bid x 4d then STOP 150mg qd x 3d then 150mg bid x 4d then STOP Smoking; continue 150mg bid x 12 weeksSmoking; continue 150mg bid x 12 weeks
varenicline*varenicline* 0.5 mg qd x 3d, then 0.5 mg bid x 4d, then 0.5 mg qd x 3d, then 0.5 mg bid x 4d, then Nausea, constipation, sleep Nausea, constipation, sleep
*restrictions*restrictions
STOp smoking and take 1 mg bid x 11 wks;STOp smoking and take 1 mg bid x 11 wks;CrCl<30 = 0.5mg bid; ESRD 0.5mg qdCrCl<30 = 0.5mg bid; ESRD 0.5mg qd
Effectiveness and Long Term Abstinence Rates of Tobacco Cessation Medications (83 studies)
3.1
2.7 2.32.1 2.0 1.9
1.5
Fiore et al., Clinical Practice Guidelines, 2008
Combination Therapy More EffectiveEffective
All combination therapies > doubled the likelihood of All combination therapies > doubled the likelihood of helping smokers achieve long term abstinence helping smokers achieve long term abstinence p g gp g g
Combination patch and long term gum or lozenge > Combination patch and long term gum or lozenge > tripled the likelihood of abstinencetripled the likelihood of abstinencetripled the likelihood of abstinence tripled the likelihood of abstinence
Only 2mg Only 2mg vareniclinevarenicline and combination longand combination long--term patch + term patch + y gy g gg ppprnprn NRT had abstinence rates significantly better than NRT had abstinence rates significantly better than patches alone patches alone
Combination therapy results in significantly higher longCombination therapy results in significantly higher long--term abstinence rates compared to term abstinence rates compared to monotherapiesmonotherapies
Fiore et al., Clinical Practice Guidelines, 2008
Effectiveness and Abstinence Rates of Effectiveness and Abstinence Rates of Combination Combination MedicationsMedications
(2-3 studies/per combination)
1.9 3.1 3.6
2.5 2.3 2 22.2
Fiore et al., Clinical Practice Guidelines, 2008
Brief Fagerstrom Test for Nicotine Brief Fagerstrom Test for Nicotine DependenceDependence
1.1. How soon after waking do you smoke your first How soon after waking do you smoke your first cigarette?cigarette?a. Less than five minutes (3 points)a. Less than five minutes (3 points)b. 5 to 30 minutes (2 points)b. 5 to 30 minutes (2 points)c 31 to 60 minutes (1 point)c 31 to 60 minutes (1 point)c. 31 to 60 minutes (1 point)c. 31 to 60 minutes (1 point)
2.2. How many cigarettes do you smoke each day?How many cigarettes do you smoke each day?a. More than 30 cigarettes (3 points)a. More than 30 cigarettes (3 points)g ( p )g ( p )b. 21 to 30 cigarettes (2 points)b. 21 to 30 cigarettes (2 points)
c. 11 to 20 cigarettes (1 point)c. 11 to 20 cigarettes (1 point)Scoring: 5Scoring: 5--6=heavy dependence; 36=heavy dependence; 3--4=moderate; 04=moderate; 0--2=light2=lightScoring: 5Scoring: 5--6=heavy dependence; 36=heavy dependence; 3--4=moderate; 04=moderate; 0--2=light2=light..
(Heatherton et al, 1991)(Heatherton et al, 1991)
TranstheoreticalTranstheoretical Model For Model For CCReadiness To ChangeReadiness To Change
5 stage model for understanding addictive5 stage model for understanding addictive5 stage model for understanding addictive 5 stage model for understanding addictive behaviors e.g. alcohol and smokingbehaviors e.g. alcohol and smoking–– PrePre--ContemplationContemplationPrePre ContemplationContemplation–– ContemplationContemplation–– PreparationPreparation–– PreparationPreparation–– ActionAction
PROMOTING MOTIVATION TO PROMOTING MOTIVATION TO QUITQUIT
Motivational Interviewing can help withMotivational Interviewing can help withMotivational Interviewing can help with Motivational Interviewing can help with those not ready to quit:those not ready to quit:“5 R’s” to enhance future quit attempts:“5 R’s” to enhance future quit attempts:5 R s to enhance future quit attempts:5 R s to enhance future quit attempts:RelevanceRelevanceRisksRisksRewardsRewardsRoadblocksRoadblocksRepetitionRepetitionRepetitionRepetition
Carpenter, Hughes@ Solomon et al, 2004Carpenter, Hughes@ Solomon et al, 2004
Strong Evidence for CounselingStrong Evidence for CounselingStrong Evidence for CounselingStrong Evidence for CounselingCounseling adds significantly to the Counseling adds significantly to the effectiveness of tobacco cessation effectiveness of tobacco cessation medications;medications;Group and individual counseling efficacy Group and individual counseling efficacy increases with treatment intensity:increases with treatment intensity:yyQuitlineQuitline counseling is an effective tool;counseling is an effective tool;Two components of counseling especiallyTwo components of counseling especiallyTwo components of counseling especially Two components of counseling especially effective: effective: problemproblem--solving/skills training+solving/skills training+
i l t ( )i l t ( )social support (group)social support (group);;Fiore et al., Clinical Practice Guidelines, 2008
Primary Care SettingPrimary Care SettingPrimary Care SettingPrimary Care Setting
Gold standard for cessation treatment isGold standard for cessation treatment isGold standard for cessation treatment is Gold standard for cessation treatment is the 5 “A’s”:the 5 “A’s”:AskAsk about tobacco useabout tobacco useAskAsk-- about tobacco useabout tobacco useAdviseAdvise-- tobacco users to stoptobacco users to stopAssessAssess-- readiness to quitreadiness to quitAssistAssist-- with the quit attemptwith the quit attemptq pq pArrangeArrange-- followfollow--up careup care
Schroeder, 2005 Schroeder, 2005
Even Brief Counseling Makes a Even Brief Counseling Makes a DifferenceDifference
Compared to smokers who receive no
30
mon
ths
counseling, smokers who receive even low intensity counseling are 1.6–2.3 times as likely to quit successfully for 5 or more months. The more sessions the better.
20
rate
at 5
+ m
n = 43 studies
10
bstin
ence
r
1.01.3
(1 01 1 6)
1.6(1.2,2.0)
2.3(2.0,2.7)
0None Miminal
(<3mins)Low-intensity
(3-10mins)Hi-intensity(>10mins)
Estim
ated
a
1.0 (1.01,1.6)
Counseling IntensityE Counseling Intensity
Fiore et al., Clinical Practice Guidelines, 2008
Number of CliniciansNumber of CliniciansMake a DifferenceMake a Difference
Compared to smokers who receive assistance from no
30
at 5
+
pclinicians, smokers who receive assistance from two or
more clinicians are 2.4–2.5 times as likely to quit successfully for 5 or more months.
20
ence
rate
ath
s 2.5 2.4
n = 37 studies
10
ated
abs
tinm
ont
1.0
1.82.5
0None One Two Three or more
N b f Cli i i T
Estim
a 1.0
Number of Clinician Types
Fiore et al., Clinical Practice Guidelines, 2008
MetaMeta--analysis (2000): Effectiveness of and estimated analysis (2000): Effectiveness of and estimated abstinence rates for number of personabstinence rates for number of person--toto--person person
MetaMeta--analysis (2000): Effectiveness of and estimated analysis (2000): Effectiveness of and estimated abstinence rates for various types of counseling and abstinence rates for various types of counseling and yp gyp g
Practical counseling (general problem -solving/skills training)
104 1.5 (1.3–1.8) 16.2 (14.0–18.5)
Fiore et al., Clinical Practice Guidelines, 2008
Combining Counseling and Medication Combining Counseling and Medication i ff ti th ith l (A)i ff ti th ith l (A)is more effective than either alone (A)is more effective than either alone (A)
30os 30
10
20
30
QU
it at
6 m
10
20
30
1.41.0 1.0
1.3
0Medication alone Medication +
counselingPerc
ent Q 0
Medication alone Medication +Quitline
Telephone Telephone QuitlineQuitline Counseling is Effective and has Counseling is Effective and has Broad Reach (A)Broad Reach (A)Broad Reach (A)Broad Reach (A)
11--800800--QUITNOW QUITNOW Direct counseling from trained staffDirect counseling from trained staffMultiMulti--language, culturally tailored serviceslanguage, culturally tailored services
Fiore et al., Clinical Practice Guidelines, 2008
TUC Counseling and Medication TUC Counseling and Medication (18 studies)(18 studies)
TreatmentOR to quit (95% CI)
Abstinence rate (95% CI)
21Medication alone 1.0 21.7
Medication and counseling 1.4(1.2-1.6) 27.6 (25.0-30.3)
Special VA PopulationsSpecial VA PopulationsRequiring IC ModelRequiring IC Model
Psychiatric disorders more commonPsychiatric disorders more commonPsychiatric disorders more common Psychiatric disorders more common among smokers;among smokers;50% with serious mental illness are50% with serious mental illness are50% with serious mental illness are 50% with serious mental illness are smokers. Psychiatric populations show:smokers. Psychiatric populations show:Hi h bidit / t lit d t t bHi h bidit / t lit d t t bHigher morbidity/mortality due to tobacco;Higher morbidity/mortality due to tobacco;Heightened risk for relapse following Heightened risk for relapse following cessation attempts;cessation attempts;Within VA, Within VA, McFallMcFall (2008) and George(2008) and George,, ( ) g( ) g
( 2006) recommend integrated care model;( 2006) recommend integrated care model;
Current and Lifetime SmokingCurrent and Lifetime Smokingggand Mental Illnessand Mental Illness
80
100
Current smokers
Lifetime Smokers
4139
55 5960
Smok
ers
4135
23
39
20
40
Perc
ent
0
20
No Mental Illness Ever Mental Illness Mental Illness Past Month
Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and mental illness: a population-based prevalence study. JAMA 2000; 284:2606–2610.
INTEGRATED CARE MODEL INTEGRATED CARE MODEL --PSYCHIATRIC/SUBPSYCHIATRIC/SUB--ABUSEABUSEIC care needed with this population due to:IC care needed with this population due to:High “no show” rates in cessation clinicsHigh “no show” rates in cessation clinicsggHigh nonHigh non--compliance; compliance; Tobacco dependence is chronic andTobacco dependence is chronic andTobacco dependence is chronic and Tobacco dependence is chronic and relapsing condition;relapsing condition;“One“One stop shopping” thru MH visits canstop shopping” thru MH visits can“One“One--stop shopping” thru MH visits can stop shopping” thru MH visits can overcome logistical barriers;overcome logistical barriers;MH providers can tailor treatmentMH providers can tailor treatment
McFallMcFall, 2006, 2006
SMOKING AND MENTAL SMOKING AND MENTAL ILLNESSILLNESS
Nicotine use w/in Schizophrenia 58%Nicotine use w/in Schizophrenia 58%--88%88%Nicotine use w/in Schizophrenia 58%Nicotine use w/in Schizophrenia 58% 88% 88% higher than general populationhigher than general populationReasons: resources stress povertyReasons: resources stress povertyReasons: resources, stress, poverty, Reasons: resources, stress, poverty, modeling, genetic factors;modeling, genetic factors;Ni ti “ li ” b l b iNi ti “ li ” b l b iNicotine may “normalize” abnormal brainNicotine may “normalize” abnormal brainactivity and improve deficits in activity and improve deficits in fxingfxing;;Need for further “culture change” w/in VA;Need for further “culture change” w/in VA;
George, 2006George, 2006
Smoking and PTSDSmoking and PTSDSmoking and PTSDSmoking and PTSD
Vets with PTSD more likely to be heavyVets with PTSD more likely to be heavyVets with PTSD more likely to be heavy Vets with PTSD more likely to be heavy smokers and less likely to quit;smokers and less likely to quit;Why: trauma cues may evoke nicotineWhy: trauma cues may evoke nicotineWhy: trauma cues may evoke nicotine Why: trauma cues may evoke nicotine withdrawalwithdrawalM k t li i t d t iM k t li i t d t iMay smoke to relieve anxiety and tensionMay smoke to relieve anxiety and tensionCessation may exacerbate depressionCessation may exacerbate depressionMH providers trained to understand and MH providers trained to understand and treat via Integrated Care modeltreat via Integrated Care modelgg
Tobacco dependence is a chronicTobacco dependence is a chronicTobacco dependence is a chronic Tobacco dependence is a chronic relapsing disease requiring repeated relapsing disease requiring repeated interventions and multiple quit attemptsinterventions and multiple quit attemptsinterventions and multiple quit attemptsinterventions and multiple quit attemptsEffective treatments exist that can Effective treatments exist that can significantly increase rates of longsignificantly increase rates of long termtermsignificantly increase rates of longsignificantly increase rates of long--term term abstinenceabstinenceV t ith h i t l ill iV t ith h i t l ill iVets with chronic mental illness require Vets with chronic mental illness require more of our attention for innovative IC more of our attention for innovative IC
