Brief ReportMobile Technology for Treatment Augmentation in Veteran Smokers With Posttraumatic Stress Disorder
Introduction
Smoking is a devastating and costly public health problem that disproportionately affects high-risk populations. Smoking prevalence has recently declined in the U.S., but has decreased only slightly among those with psychiatric conditions such as posttraumatic stress disorder (PTSD),1, 2, 3, 4, 5 and among military veterans.6, 7, 8 Veterans with PTSD are at especially high risk of smoking initiation and relapse.7 Veterans deployed to Iraq and Afghanistan smoke at rates exceeding the general population, ranging from 32% to 48%,6, 9, 10 and are at risk of inadequate treatment engagement in Veterans Affairs clinics.11, 12, 13
To address this need, McFall and colleagues developed an integrated care (IC)14 office-based protocol that delivers eight weekly PTSD-informed cognitive behavioral therapy sessions plus pharmacotherapy for smoking cessation, followed by monthly follow-up sessions. In an RCT with 943 veterans with PTSD, IC was found to double 6-month bioverified smoking abstinence rates compared with smoking-cessation clinic treatment (30-day point prevalence abstinence, 13.8% vs 5.9%, p=0.001). However, nonattendance limited efficacy of IC. Total sessions attended mediated 29.5% of the treatment effect (95% CI=26.6%, 32.5%), and only 47% of participants in IC attended more than eight sessions.
Mobile technology is a promising approach to improve treatment engagement, given the popularity of smartphones and the capability of delivering behavioral coping strategies instantaneously at any time. To that end, the National Center for PTSD designed Stay Quit Coach (SQC, https://mobile.va.gov/app/stay-quit-coach), a no-cost companion mobile application to the IC protocol to provide evidence-based techniques to manage both smoking urges and PTSD symptoms. To the authors’ knowledge, SQC is the only publicly available app that targets PTSD symptoms associated with smoking lapse,4, 8, 15, 16 including a controlled breathing feature to target hyperarousal17 and personalized coping plans to manage stress and emotional numbing. SQC includes features positively associated with popularity and user-rated quality, including proactive alerts and personalized tools targeting the “5A’s” (Ask, Advise, Assess, Assist, Arrange).16 SQC provides motivational messages, a feature positively associated with 6-month abstinence18 and a money-saved tracker. Access to these tools between sessions may help users manage the stress of quitting and promote engagement. In an RCT comparing contingency management, four sessions of IC, and pharmacotherapy with or without SQC in smokers with PTSD (n=11),19 participants receiving SQC (n=4) rated SQC as helpful, though no differences in smoking outcomes between groups were observed.
To further investigate the feasibility and potential impact of SQC on session attendance, smoking outcomes, and PTSD symptoms, an open uncontrolled pilot study incorporating SQC into the full IC protocol was conducted with 20 veterans with PTSD.
Section snippets
Methods
Consistent with the original study by McFall and colleagues, the IC protocol included eight weekly sessions with quit date in session 5, and monthly booster sessions thereafter.14 Participants were instructed to use SQC whenever desired. Participants were optionally prescribed one or more smoking-cessation medications, consistent with standard treatment guidelines. The study received University of California, San Francisco IRB approval and written informed consent was obtained from
Results
Of 93 veterans screened, 39 were eligible. Eleven (28.2%) of those eligible declined because of either geographic distance or time commitment of office visits; seven (17.9%) did not respond to outreach; one (2.6%) was moving; and 20 (51.3%) enrolled in the study (baseline characteristics summarized in Table 1). Thirteen participants (65%) attended all ten scheduled sessions; four (20%) did not adhere to the protocol schedule but completed follow-up measures; and three (15%) were lost to
Discussion
Results demonstrate that SQC is a feasible, acceptable intervention that was successfully incorporated into the IC protocol. The proportion of participants who attended more than eight scheduled sessions was higher than that observed in the original IC study14 (65% vs 47%), suggesting that SQC may promote engagement and retention in treatment. Three-month bioverified 30-day abstinence rates were promising, given the low cessation rates in smokers with PTSD.1−5,14
Conclusions
In summary, results demonstrate the feasibility of incorporating a mobile application, SQC, into IC treatment in a sample of veteran smokers with PTSD, a vulnerable population with a higher smoking prevalence and lower quit rates than the general population. Participants rated SQC as “moderately” acceptable and most participants reported using the app regularly throughout the study period. Future RCTs could examine whether inclusion of SQC in the IC protocol improves treatment retention and
Acknowledgments
We acknowledge the support of the San Francisco Veterans Affairs Health Care System, the Veterans Integration to Academic Leadership program and the University of California, San Francisco/San Francisco Veterans Affairs Health Care System Addiction Research Program for supporting the recruitment, facilities, and supporting resources needed to complete the study. We also acknowledge Kelsey Laird, PhD, Brooke Lasher, BA, Megan Jones, MS, Andrea Vanderlugt, LCSW, and Shahrzad Hassanbeigi Daryani,
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