Tobacco treatment as augmentation to Cognitive Processing Therapy for PTSD

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Research Background and Current Research Interests: I have been a tobacco researcher for ten years, beginning as an undergraduate and continuing through postdoctoral work. My research background includes treatment development, evaluation and implementation for tobacco dependence. I am currently a Project Director at the National Center for Posttraumatic Stress Disorder (NCPTSD), Women's Health Sciences Division. Working with Veterans with PTSD has alerted me to the high prevalence of tobacco use in this population and the interplay between tobacco use and PTSD recovery. My background in tobacco treatment development and evaluation for other high risk psychiatric and medical populations makes me well suited to investigate treatments for individuals with comorbid tobacco dependence and PTSD. In order to pursue this research, I require training in: PTSD research methods; manualized treatment development for PTSD and tobacco cessation; and clinical trials research including trial design, management and sophisticated data analysis. The NCPTSD is an ideal environment to gain knowledge in these areas. A CDA-2 award would allow me to receive the necessary training to pursue a program of research in treatment for comorbid PTSD and tobacco dependence. Summary of the Proposed Research: Individuals with PSTD use tobacco at high rates and have a high prevalence of tobacco-related disease. The mechanisms for the tobacco use-PTSD comorbidity have not been determined. Two possible mechanisms include: (1) that nicotine interferes with PTSD recovery and (2) that tobacco is used as self-medication for PTSD. Animal models suggest that nicotine may interfere with recovery from PTSD by enhancing passive avoidance and contextual fear conditioning, as well as inhibiting extinction. These findings have not been tested for replication in humans. Individuals with PTSD report using tobacco to manage PTSD symptoms. However, the data is less clear as to whether tobacco use decreases PTSD symptoms. Tobacco cessation results in withdrawal symptoms that mimic PTSD, including exacerbation of negative affect, further complicating assessment of tobacco use and PTSD symptom relations. Additionally, PTSD symptoms serve as triggers for tobacco use and therefore could result in craving for tobacco and relapse in those recently abstinent. Research is needed to investigate the mechanisms underlying potential reciprocal influences of PTSD and tobacco use in order to develop treatments for these often comorbid disorders. The proposed research aims to examine the effect of tobacco on PTSD symptoms and PTSD recovery as well as the effect of PTSD recovery on tobacco use. This study has 3 aims: (1) to evaluate whether tobacco use interferes with recovery from PTSD during empirically based, trauma focused PTSD treatment. (2) To gather preliminary data about whether tobacco use alleviates PTSD symptoms among continued tobacco users vs. recent quitters. (3) To explore the impact of recovery from PTSD treatment on tobacco use quantity and frequency, tobacco withdrawal symptoms, and craving for tobacco. To test these aims, we propose a randomized two group design where 50 participants are assigned to receive either tobacco treatment (Contingency Management plus Cognitive Behavioral Therapy) or control treatment (Health Education) before completing Cognitive Processing Therapy (CPT) for PTSD. Study outcome variables will be PTSD symptom severity following CPT, PTSD symptom severity during tobacco cessation treatment, and tobacco use and tobacco withdrawal during CPT. Training received during this award will prepare this candidate to submit a Merit Review application for a large scale clinical trial focused on testing the long-term efficacy and mechanisms of change of during treatment for comorbid tobacco dependence and PTSD.