Principle Investigator: Corinne N. Kacmarek, PhD
Co-Investigators: Melanie E. Bennett, PhD; Karen Besterman-Dahan, PhD; Richard Goldberg, PhD., Julie Kreyenbuhl, PharmD, PhD.
Funding: VISN 5 MIRECC Pilot Study

Smoking tobacco products remains the leading cause of death in the United States (U.S. Department of Health and Human Services, 2020). Veterans with serious mental illness (SMI; schizophrenia spectrum, bipolar spectrum, and other psychotic disorders) have among the highest smoking rates in VA. Nearly half (48%) of Veterans with SMI smoke, which is triple the rate of smoking among Veterans without any mental illness (Duffy et al., 2012). Smoking shortens the life expectancy of those with SMI by 10-15 years (Dickerson et al., 2018). Individuals with SMI are more likely to make a quit attempt than those without SMI (Han et al., 2023), and 70% of Veterans with SMI want to quit (Duffy et al., 2011). Tobacco cessation (quit) medication is safe and effective for Veterans with SMI who smoke (Anthenelli et al., 2016; Tobacco Use and Dependence Guideline Panel, 2008; U.S. Department of Health and Human Services, 2020), and is essential to quitting for individuals with SMI. All seven FDA-approved (quit) medications are available in VA , but Veterans with SMI are less likely to be offered these medications (Ignacio et al., 2018): The most effective quit medication, varenicline, is offered to just 4% of Veterans with SMI (Duffy et al., 2012). Veterans with SMI are also less likely to be advised to quit by their health care providers (Duffy et al., 2012).

Mental health providers have frequent contact and strong relationships with Veterans with SMI; thus, increasing their involvement in quit treatment may expand the reach of this life-saving treatment. Further, as an integrated health care system, VA is in a unique position to support multidisciplinary quit treatment. With support from a VISN 5 MIRECC pilot grant and feedback from members of the VISN 5 Veteran Stakeholder Forum, we are conducting interviews with providers and Veterans to better understand barriers to smoking treatment. In interviews with 20 VA Maryland providers who work with Veterans with SMI, many shared that they view smoking as harmful to Veteran health, but do not routinely follow-up about smoking after initial discussions. Many providers feel uncomfortable or ill-equipped to talk about smoking due to observing unsuccessful quit attempts, having limited familiarity with relevant VA resources, worrying about side effects of quit medication, and prioritizing psychiatric symptoms, alcohol, and cannabis over smoking. These barriers have been well-documented outside of VA, as well (Huddlestone et al., 2022; Malone et al., 2018; Sheals et al., 2016; Tobacco Use and Dependence Guideline Panel, 2008).

We are also interviewing Veterans with SMI who smoke about their experiences with smoking, interest in quitting, and discussions with health care providers. So far, we have learned that Veterans describe a linkage between smoking and mental health; and though they do not expect to be asked about smoking by their mental health providers, most said they would welcome follow-up conversations about smoking and consider medication or counseling, if offered. Additionally, most Veterans have quit, but without the assistance of medication or psychosocial support from a health care provider.

In sum, strategies that empower mental health providers to deliver evidence-based quit treatment, like educational outreach and skills-based training, may improve provider’s confidence and ability to deliver quit interventions and also be welcomed by Veterans trying to quit smoking.

References:

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