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1.  Engagement and abstinence among users of a smoking cessation text message program for veterans 
Addictive behaviors  2016;62:47-53.
SmokefreeVET is a text messaging smoking cessation program available to veterans enrolled in the Veterans Health Administration. SmokefreeVET was developed in collaboration with the National Cancer Institute as part of the SmokefreeTXT initiative.
To evaluate the real world use of and effectiveness of the SmokefreeVET program for SmokefreeVET users who enrolled between 2013 and 2014.
Demographics and smoking behavior of 1,470 SmokefreeVET users who enrolled between 2013 and 2014 were analyzed. Latent growth mixture modeling was used to identify discrete classes of SmokefreeVET users based on engagement patterns. Multi-level modeling determined class differences in abstinence.
The average age of the SmokefreeVET user was 48, 75% of users were male, and 84% were daily smokers. After five weeks, 13% of all users reported abstinence from smoking. Five statistically distinct engagement classes of SmokefreeVET users were identified. Highly engaged classes were significantly less likely to opt-out and more likely to report abstinence. Over 60% of users who were classified as high engagers throughout the program reported abstinence 5 weeks after their quit date. Users were more likely to report abstinence after two weeks if they used smoking cessation medication than those that did not use medication (OR=9.01, p<.001).
SmokefreeVET may be effective at supporting abstinence among a real world group of highly engaged users. Smoking cessation medication use was also associated with abstinence in SmokefreeVET users. Engagement appears to be a critical component when assessing the efficacy of a text messaging smoking cessation intervention.
PMCID: PMC5144826  PMID: 27318948
smoking; tobacco; cessation; mHealth; engagement; veteran
2.  Cigarette Smoking and Sociodemographic, Military, and Health Characteristics of Operation Enduring Freedom and Operation Iraqi Freedom Veterans 
Public Health Reports  2016;131(5):714-727.
We examined the sociodemographic, military, and health characteristics of current cigarette smokers, former smokers, and nonsmokers among Operation Enduring Freedom (OEF) / Operation Iraqi Freedom (OIF) veterans and estimated smoking prevalence to better understand cigarette use in this population.
We analyzed data from the US Department of Veterans Affairs (VA) 2009-2011 National Health Study for a New Generation of US Veterans. On the basis of a stratified random sample of 60 000 OEF/OIF veterans, we sought responses to a 72-item questionnaire via mail, telephone, or Internet. Cigarette smoking status was based on self-reported cigarette use in the past year. We used multinomial logistic regression to evaluate associations between smoking status and sociodemographic, military, and health characteristics.
Among 19 911 veterans who provided information on cigarette smoking, 5581 were current smokers (weighted percentage: 32.5%, 95% confidence interval [CI]: 31.7-33.2). Current smokers were more likely than nonsmokers or former smokers to be younger, to have less education or income, to be separated/divorced or never married/single, and to have served on active duty or in the army. Comparing current smokers and nonsmokers, some significant associations from adjusted analyses included the following: having a Mental Component Summary score (a measure of overall mental health) above the mean of the US population relative to below the mean (adjusted odds ratio [aOR] = 0.81, 95% CI: 0.73-0.90); having physician-diagnosed depression (aOR = 1.52, 95% CI: 1.33-1.74), respiratory conditions (aOR = 1.16, 95% CI: 1.04-1.30), or repeated seizures/blackouts/convulsions (aOR = 1.80, 95% CI: 1.22-2.67); heavy alcohol use vs never use (aOR = 5.49, 95% CI: 4.57-6.59); a poor vs excellent perception of overall health (aOR = 3.79, 95% CI: 2.60-5.52); and being deployed vs nondeployed (aOR = 0.87, 95% CI: 0.78-0.96). Using health care services from the VA protected against current smoking.
Mental and physical health, substance use, and military service characteristics shape cigarette-smoking patterns in OEF/OIF veterans.
PMCID: PMC5230820  PMID: 28123213
veterans; cigarettes; smoking; OEF/OIF; Operation Iraqi Freedom; Operation Enduring Freedom; health; Afghanistan; Iraq
3.  Health Care Expenditures Attributable to Smoking in Military Veterans 
Nicotine & Tobacco Research  2014;17(5):586-591.
The health effects of cigarette smoking have been estimated to account for between 6%–8% of U.S. health care expenditures. We estimated Veterans Health Administration (VHA) health care costs attributable to cigarette smoking.
VHA survey and administrative data provided the number of Veteran enrollees, current and former smoking prevalence, and the cost of 4 types of care for groups defined by age, gender, and region. Cost and smoking status could not be linked at the enrollee level, so we used smoking attributable fractions estimated in sample of U.S. residents where the linkage could be made.
The 7.7 million Veterans enrolled in VHA received $40.2 billion in VHA provided health services in 2010. We estimated that $2.7 billion in VHA costs were attributable to the health effects of smoking. This was 7.6% of the $35.3 billion spent on the types of care for which smoking-attributable fractions could be determined. The fraction of inpatient costs that was attributable to smoking (11.4%) was greater than the fraction of ambulatory care cost attributable to smoking (5.3%). More cost was attributable to current smokers ($1.7 billion) than to former smokers ($983 million).
The fraction of VHA costs attributable to smoking is similar to that of other health care systems. Smoking among Veterans is slowly decreasing, but prevalence remains high in Veterans with psychiatric and substance use disorders, and in younger and female Veterans. VHA has adopted a number of smoking cessation programs that have the potential for reducing future smoking-attributable costs.
PMCID: PMC5009451  PMID: 25239960
Journal of Addiction Medicine  2011;5(1):79-83.
The purpose of this clinical demonstration project was to increase the reach of effective treatments, such as pharmacotherapy and telephone or web based support, by offering these treatments in a low-cost and convenient manner to a population of veterans.
Six hundred nine veteran smokers who had served in the military since September 11, 2001 were contacted by invitational letters. Veterans indicating interest in further contacts received telephone calls using standardized scripts that offered referral to the National Cancer Institute’s Smoking QuitLine, web-based counseling, and local Veteran Affairs pharmacologic treatment for smoking cessation.
Seven percent of survey recipients participated in the clinical program. At two months follow-up, 23% of participants providing follow-up information reported maintaining smoking abstinence. This clinical demonstration project was associated with a reach of 8.6% (number of smokers who accessed the intervention/the number of targeted smokers), an efficacy of 26% i.e., number of abstinent smokers at 8 weeks/number who accessed the intervention), and an impact of 2.2% (number of abstinent smokers at 8 weeks/number of targeted smokers).
Results suggested that this project enhanced access to care and promoted short-term smoking cessation in veterans who have served since September 11. 2001.
PMCID: PMC3309401  PMID: 21769051
smoking; tobacco; military veterans; public health; telemedicine
5.  Tobacco Use Among Iraq- and Afghanistan-Era Veterans: A Qualitative Study of Barriers, Facilitators, and Treatment Preferences 
Military service and combat exposure are risk factors for smoking. Although evidence suggests that veterans are interested in tobacco use cessation, little is known about their reasons for quitting, treatment preferences, and perceived barriers to effective tobacco use cessation treatment. Our study objective was to elicit perspectives of Iraq- and Afghanistan-era veterans who had not yet quit smoking postdeployment to inform the development of smoking cessation services for this veteran cohort.
We conducted 3 focus groups among 20 participants in October 2006 at the Durham Veterans Affairs Medical Center to explore issues on tobacco use and smoking cessation for Iraq- and Afghanistan-era veterans who continued to smoke postdeployment. We used qualitative content analysis to identify major themes and organize data.
Veterans expressed the belief that smoking was a normalized part of military life and described multiple perceived benefits of smoking. Although veterans expressed a high level of interest in quitting, they listed several behavioral, situational, and environmental triggers that derailed smoking cessation. They expressed interest in such cessation treatment features as flexible scheduling, free nicotine replacement therapy, peer support, and family inclusion in treatment.
Our results indicate that the newest cohort of veterans perceives smoking as endemic in military service. However, they want to quit smoking and identified several personal and environmental obstacles that make smoking cessation difficult. Our findings may inform programmatic efforts to increase successful quit attempts in this unique veteran population.
PMCID: PMC3359099  PMID: 22338598
6.  Public Health Clinical Demonstration Project for Smoking Cessation in Veterans with Posttraumatic Stress Disorder 
Addictive behaviors  2009;35(1):19-22.
Veterans with posttraumatic stress disorder are at high risk for smoking and experience difficulty with smoking cessation. We designed this clinical demonstration project to provide a low-cost, feasibly implemented smoking cessation intervention that would maximize the number of smokers who accessed the intervention. Five hundred eighty-four veteran smokers were contacted by invitational letters. Interested veterans received follow-up telephone calls using standardized scripts offering three intervention resources: 1) a referral to the National Cancer Institute’s Smoking Quitline, 2) web-based counseling, and 3) local Veteran Affairs pharmacologic treatment for smoking cessation. Twenty-three percent of survey recipients participated in the clinical program. Two months after these resources were offered by phone, follow-up phone calls indicated that 25% of participants providing follow-up information reported maintaining smoking abstinence. 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]), meaning that 2.6% of the total number of targeted smokers reported 8 week abstinence. Results suggested that this brief, low-cost intervention was feasible and promoted smoking cessation in veterans with posttraumatic stress disorder.
PMCID: PMC2763989  PMID: 19737675
smoking; posttraumatic stress disorder; military veterans; public health; telehealth

Results 1-6 (6)