Background: Veterans smoke at a higher rate (30%) than the U.S. adult population (21%), and veterans with PTSD have even higher rates of smoking (53-66%). Evidence has shown that any tobacco dependence treatment strategy must be integrated in the health care system because consistent and effective delivery of tobacco cessation requires coordinated interventions. Persistent tobacco users typically cycle through multiple periods of relapse and remission. Veterans with PTSD (279,256 in 2005) who are treated for smoking cessation may need more comprehensive aid to be successful. Failure to appreciate the chronic nature of tobacco dependence may impede comprehensive and consistent treatment. Care management using telehealth has been shown to improve access to care while reducing costs for veterans with chronic diseases and has the potential to coordinate smoking cessation with care for other chronic diseases. Nurses have successfully managed chronic diseases using telehealth by focusing on increasing self-management, positive behaviors and knowledge. Nurses are vital to increasing the level of support in the community through education and motivation and by responding to medical events in order to improve veterans' health. Objectives: The study is designed to determine if adding motivational counseling and care management using the PTSD Health Buddy to usual care improves smoking quit rates of veterans with PTSD.
Specific Aims are to compare: 1) self-reported quit attempts, progression through the stages of change, and quit rates, 2) patient perception of care coordination, and 3) changes in PTSD symptoms in veteran smokers with PTSD who receive a nurse-driven telephonic motivational counseling intervention triggered by responses to stage-based smoking cessation questions in addition to usual care to those who receive usual care only. Methods: This randomized controlled trial will assess the effectiveness of tobacco cessation treatment for veterans with PTSD. We will recruit 120 veterans who smoke and who are using or are eligible to use the PTSD Health Buddy program from the Eastern Colorado Health Care System in order to detect a 24 percent increase in quit attempts. Subjects will be randomized to usual tobacco cessation care (control) and care management using telehealth and stage-based motivational counseling in addition to usual care (experimental). The PTSD Health Buddy has an already-developed smoking cessation module which will be the telehealth system used in this trial. Standardized instruments will be used to assess stage of change, care coordination, and PTSD symptoms in all subjects. Demographics, clinical characteristics and outcome measurements will be compared between groups. Outcome measurements will occur at the end of the three- month intervention, and at six-month post-study follow-up. Chi-square tests for quit rate and other categorical variables and t-tests for continuous variables will be used.
Anticipated Impacts on Veteran's Healthcare: Our study provides a nurse-driven integrated care management model of care using telehealth and stage-based motivational counseling to help veterans with PTSD quit smoking. This is important because veterans with PTSD have higher rates of smoking and are less likely to successfully quit than other veterans. Given the high rates of PTSD in veterans and the lifetime ill effects of tobacco abuse, this is a particularly timely and critical endeavor.
