Identifying Effective Treatment for Veterans Unwilling to Quit Smoking

目的和理由：烟草使用是美国过早死亡的主要可预防原因。 退伍军人吸烟率高于美国人口（21.6%对15%），因此遭受 与吸烟有关的疾病。为了减少巨大的健康和经济危害， 在退伍军人中吸烟，我们需要一个全面的方法来吸引所有吸烟的退伍军人。 有效帮助他们戒烟的治疗。不幸的是，大多数吸烟者不愿意戒烟 在任何给定的时间（70%-90%），我们知道如何有效地吸引这些吸烟者， 治疗并帮助他们戒烟。标准建议对这些吸烟者进行干预，简要建议戒烟， 对于动员大多数吸烟者进行辅助戒烟尝试来说太小了。因此，一个关键的公共卫生 挑战是确定成功的干预措施，激励吸烟者尝试戒烟，并改善他们的健康状况。 成功的可能性，当他们尝试。拟议的研究将通过以下方式解决吸烟治疗的差距： 评估增强型慢性病护理，这是一种旨在增加治疗参与度的干预措施， 退伍军人最初不愿意戒烟。加强慢性护理提供持续的 旨在促进变革准备的动机干预和人际支持， 获得适合所有吸烟者的戒烟和戒烟治疗（这两种治疗都是 愿意和不愿意放弃尝试）。减少治疗是一个值得注意的除了慢性护理，因为它 可以增加接受吸烟治疗的吸烟者的比例，增加戒烟尝试， 吸烟者最初不愿意戒烟。加强慢性护理将与标准护理进行比较 护理（每年戒烟一次的简短建议）对临床和公共卫生具有重要意义的标准：长期 长期禁欲（主要结局）、治疗范围、成本效益和实施。等 全面的数据将允许确定VA临床实践的最佳吸烟治疗策略。 方法：我们将使用严格的2组随机对照试验（RCT）评估这些干预措施。 每天吸烟，但不愿意进入戒烟治疗的退伍军人（绝大多数 吸烟者），将有资格参加，没有义务戒烟或减少吸烟。参与者（N=500） 将被随机分配至以下治疗之一：1）加强慢性护理（n=250）或2）标准护理 （n=250）。这些干预条件将持续2年，以便分析其累积影响， 禁欲（主要结局）和治疗使用，并收集有关因素的信息，包括费用- 有效性，这可能会影响加强慢性病护理的实施和有效性。 创新/意义：这项研究具有高度创新性，因为它将是第一项实验性的研究。 评估不愿意尝试戒烟的吸烟者的长期护理。它将提供最 迄今为止，对慢性护理吸烟治疗的全面评估，严格测试了 长期护理干预的有效性，包括持续的动机干预， 循证减量和戒烟治疗，同时收集二次实施 为后续的实施工作和研究提供信息。这项研究具有重要的临床和公共 健康意义，因为吸烟在退伍军人中特别普遍，是主要的可预防原因 疾病和残疾。在医疗保健中治疗吸烟的成功有限，因为吸烟者使用 吸烟治疗太少，他们接受的治疗通常是中等强度的 和有效性。拟议的研究建立在我们的专业知识和先前的研究结果，以解决这些问题 关键的知识差距，通过确定一种干预措施，随着时间的推移，应该大大提高退伍军人的 使用有效的治疗方法和戒烟成功，从而导致烟草相关的 发病率和死亡率。

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.