This project demonstrated that the impact of the approach (low cost telephone and web based care with invitational letters) was associated with a 2.6% impact rate. This is a favorable response compared to typical smoking cessation public health approaches with results that suggest an impact rate of approximately 1% (An et al., 2006
; Cummings et al., 2006
There was a relatively low undeliverable survey rate (5%) in the current project, likely because veterans registered for treatment at the VA typically update their mailing addresses as part of their clinical care. The proportion of smokers completing the mail survey (42%) was relatively high, suggesting high interest in smoking cessation resources. Consistent with this observation, the smokers who responded to the survey were generally interested in the available resources. This clinical demonstration engaged 125 smokers in smoking cessation efforts. As a result, this project improved the reach of existing clinical efforts addressing smoking cessation.
Based on follow-up data, of those who responded to invitation letters and talked to project personnel, 55% set a quit date. Eight weeks after the final contact with project personnel, 25% were abstinent from tobacco. Combined with the quit rate (38%) in our previous efforts with a similar protocol (Beckham et al., 2008
), preliminary evidence suggests the potential for short-term efficacy of this intervention. This is consistent with clinical practice guidelines indicating that brief interventions, such as the one described in this report, effectively promote smoking cessation (Fiore et al., 2008
Comparing reach for cohorts within this project, the higher response rate in the PTSD clinic cohort could have been attributable to patients’ regular clinic visits, as opposed to the second cohort, which consisted of registered veterans with a range of visit frequency. In contrast, abstinence rates from the second cohort suggest the addition of QuitNet® might have increased the efficacy. In terms of impact, this clinical demonstration project was associated with a 2.6% impact (i.e., reach [31.1% of smokers accessed intervention] by efficacy [8.4% of those accessing intervention quit]).
A previous report on this intervention initially targeted 1500 veterans, without information on how many were smokers (Beckham et al., 2008
). Assuming a smoking rate of 22.2% in veterans (VHA, 2008
), this previous report targeted 333 smokers. A total of 31 smokers accessed the intervention, for a reach of 9%. Of these, nine reported smoking abstinence, for an efficacy of 29%, yielding an impact of 2.7%. As a result, the impact from the current report is slightly lower than the estimated impact from the previous report. The similar rates observed in this report compared to the previous report (Beckham et al., 2008
) are noteworthy because the sample in this project were PTSD smokers, suggesting that this approach may be as potentially useful in PTSD smokers.
Because there was no control group of smokers to use for comparison in this study, it is difficult to determine what the rate of smoking cessation would have been during the eight week intervention, which we will refer to as spontaneous smoking cessation. In studies following smokers who were not assessed for psychiatric disorders for three to five years, a range of 8 to 13% of smoking cessation was observed (Lennox & Taylor, 1994
; Osler, Prescott, Hein, & Schnohr, 1999
; Wagenknecht et al., 1993
). Based on these observations, it appears that a small but significant number of smokers spontaneously quit smoking over a period of several years. However, the number of veteran smokers with PTSD who would be expected to quit over a brief time period, such as the eight weeks used in our project, is likely quite small. Some information can be gleaned from using historical quit rates from our sample of smokers, who reported on the initial questionnaire whether they were still smoking and the time since their most recent cigarette. Using this information for the 584 patients returning the questionnaire, only one patient (0.2%) reported successfully quitting smoking in the month prior to completing the questionnaire. Based on self-report, it appears that the smokers targeted by this intervention had higher quit rates during the intervention, relative to the month prior to the intervention. Future research could address this issue more directly.
This project was also limited by low follow-up rates, the absence of biological verification of smoking abstinence and non-experimental design of the approach. Low follow-up rates may have been due to a lack of payment for follow-up completion (which is usually present in research studies). Based on the promising smoking cessation rates in this project, randomized research using a biological verification method focused on further evaluation of this public health initiative is warranted.
Despite these limitations, this report contributed to the evidence supporting the use of public health approaches to reduce smoking in veterans, including those with PTSD. These approaches can be low cost, increase both reach and impact, and may help reduce the health care costs and improve quality of life in veterans.