Identifying Effective Treatment for Veterans Unwilling to Quit Smoking

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Aims and Rationale: Tobacco use is the leading preventable cause of premature death in the United States. Veterans smoke at a higher rate than the U.S. population (21.6% vs. 15%), and therefore suffer disproportionately from smoking–related illness. To reduce the enormous health and economic harms of smoking amongst Veterans, we need a comprehensive approach to engage all Veterans who smoke in treatment that effectively helps them stop smoking. Unfortunately, most smokers are unwilling to make a quit attempt at any given time (70%-90%), and we know little about how to effectively engage such smokers in treatment and help them quit. The standard recommended intervention for such smokers, brief advice to quit, is far too minimal to mobilize most smokers to make an aided quit attempt. Thus, a critical public health challenge is to identify successful interventions that motivate smokers to make quit attempts and improve their likelihood of success when they try. The proposed research will address gaps in smoking treatment by evaluating Enhanced Chronic Care, an intervention designed to increase treatment engagement and abstinence amongst Veterans initially unwilling to quit smoking. Enhanced Chronic Care provides ongoing motivational interventions and interpersonal support designed to promote readiness to change, with facilitated access to both smoking reduction and cessation treatments that are appropriate for all smokers (both those willing and unwilling to make quit attempts). Reduction treatment is a notable addition to chronic care since it can increase the proportion of smokers who enter smoking treatment, and increase quit attempts and abstinence amongst smokers initially unwilling to quit. Enhanced Chronic Care will be compared with Standard Care (brief advice to quit once per year) on criteria that are of great clinical and public health importance: long- term abstinence (primary outcome), treatment reach, cost-effectiveness, and implementation. Such comprehensive data will permit identification of an optimal smoking treatment strategy for VA clinical practice. Methods: We will evaluate these interventions using a rigorous 2-arm randomized controlled trial (RCT). Veterans who smoke daily, but who are not willing to enter smoking cessation treatment (the vast majority of smokers), will be eligible to participate, with no obligation to quit or reduce their smoking. Participants (N=500) will be randomized to one of the following treatments: 1) Enhanced Chronic Care (n=250) or 2) Standard Care (n=250). These intervention conditions will last 2 years to permit analysis of their cumulative impact on abstinence (primary outcome) and treatment use, and to gather information on factors, including cost- effectiveness, that could affect the implementation and effectiveness of Enhanced Chronic Care. Innovation/Significance: This research is highly innovative in that it will be the first study to experimentally evaluate chronic care for smokers who are unwilling to make a quit attempt. It will provide the most comprehensive evaluation of a chronic care smoking treatment to date, one that rigorously tests the effectiveness of a chronic care intervention involving an ongoing motivational intervention with ready access to evidence-based reduction and cessation treatment, while simultaneously gathering secondary implementation data to inform subsequent implementation efforts and research. This research has important clinical and public health significance because smoking is especially common amongst Veterans and is the leading preventable cause of disease and disability. Success in treating smoking in healthcare has been limited because smokers use smoking treatments far too infrequently and the treatments that they do receive are typically of modest intensity and effectiveness. The proposed research builds on our expertise and prior research findings to address these critical knowledge gaps by identifying an intervention that, over time, should greatly increase both Veterans’ use of effective treatments and their quitting success, thereby leading to significant declines in tobacco-related morbidity and mortality.