Identifying Effective Treatment for Veterans Unwilling to Quit Smoking

目的和理由：在美国，烟草使用是导致过早死亡的主要可预防原因。 退伍军人的吸烟率高于美国人口(21.6%比15%)，因此 不成比例地死于吸烟相关的疾病。为了减少对健康和经济的巨大危害 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 有效地帮助他们戒烟的治疗。不幸的是，大多数吸烟者不愿戒烟。 在任何给定的时间尝试(70%-90%)，我们对如何有效地让这些吸烟者参与到 治疗并帮助他们戒烟。对这类吸烟者的标准建议是干预，简短的戒烟建议， 太少了，不能动员大多数吸烟者进行辅助戒烟尝试。因此，一个关键的公共卫生 挑战是找出成功的干预措施，激励吸烟者尝试戒烟，并提高他们的 当他们尝试的时候，成功的可能性。拟议的研究将通过以下方式解决吸烟治疗方面的差距 评估增强型慢性护理，这是一种旨在提高治疗参与度和 最初不愿戒烟的退伍军人的戒烟情况。增强型慢性护理可持续提供 旨在促进变革准备的激励性干预和人际支持，并在 获得适用于所有吸烟者的减烟和戒烟治疗(两者均适用 愿意和不愿意做出戒烟尝试)。减少治疗是慢性护理的一个值得注意的补充，因为它 可以增加吸烟者接受吸烟治疗的比例，并增加戒烟尝试和 最初不愿戒烟的吸烟者的戒烟情况。增强型慢性护理将与标准护理进行比较 根据对临床和公共卫生非常重要的标准提供护理(每年戒烟一次的简短建议)：长期- 长期禁欲(主要结果)、治疗范围、成本效益和实施情况。是这样的 综合数据将有助于确定VA临床实践的最佳吸烟治疗策略。 方法：我们将使用严格的双臂随机对照试验(RCT)来评估这些干预措施。 每天吸烟，但不愿接受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) 将随机接受以下治疗之一：1)强化慢性护理(n=250)或2)标准护理 250例。这些干预条件将持续两年，以便分析其对 禁欲(主要结果)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护理的实施和效果。 创新/意义：这项研究具有很高的创新性，因为它将是第一次进行实验研究 评估对不愿戒烟的吸烟者的长期护理。它将提供最大的 到目前为止，对慢性护理吸烟治疗的综合评估，一项严格测试 长期护理干预的有效性，包括持续的动机干预，并随时可以获得 循证减少和戒断治疗，同时收集二次执行情况 为后续的执行工作和研究提供信息的数据。本研究具有重要的临床意义和社会意义。 健康意义，因为吸烟在退伍军人中特别常见，是主要的可预防原因 疾病和残疾。在医疗保健领域治疗吸烟的成功受到限制，因为吸烟者使用 吸烟治疗太少了，而且他们接受的治疗通常都是中等强度的 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成果的基础上，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，应该会大大增加两名退伍军人的 有效治疗的使用及其戒烟的成功，从而导致与烟草有关的 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.