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Journal of Dual Diagnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wjdd20
Acceptance and Commitment Therapy Smoking Cessation Treatment for Veterans with Posttraumatic Stress Disorder: A Pilot Study ab
a
c
Megan M. Kelly PhD , Hannah Sido PsyD , John P. Forsyth PhD , Douglas M. Ziedonis MD b
b
de
MPH , David Kalman PhD & Judith L. Cooney PhD a
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA
b
University of Massachusetts Medical School, Worcester, Massachusetts, USA
c
University at Albany, State University of New York, Albany, New York, USA
d
VA Connecticut Healthcare System, Newington, Connecticut, USA
e
Click for updates
University of Connecticut School of Medicine, Farmington, Connecticut, USA Accepted author version posted online: 09 Dec 2014.
To cite this article: Megan M. Kelly PhD, Hannah Sido PsyD, John P. Forsyth PhD, Douglas M. Ziedonis MD MPH, David Kalman PhD & Judith L. Cooney PhD (2015) Acceptance and Commitment Therapy Smoking Cessation Treatment for Veterans with Posttraumatic Stress Disorder: A Pilot Study, Journal of Dual Diagnosis, 11:1, 50-55, DOI: 10.1080/15504263.2014.992201 To link to this article: http://dx.doi.org/10.1080/15504263.2014.992201
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JOURNAL OF DUAL DIAGNOSIS, 11(1), 50–55, 2015 C Taylor & Francis Group, LLC Copyright ISSN: 1550-4263 print / 1550-4271 online DOI: 10.1080/15504263.2014.992201
BRIEF REPORTS
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Acceptance and Commitment Therapy Smoking Cessation Treatment for Veterans with Posttraumatic Stress Disorder: A Pilot Study Megan M. Kelly, PhD,1,2 Hannah Sido, PsyD,1 John P. Forsyth, PhD,3 Douglas M. Ziedonis, MD, MPH,2 David Kalman, PhD,2 and Judith L. Cooney, PhD4,5
Objective: Veterans with PTSD smoke at rates two to three times higher than the general population, while their quit rate is less than half that of the general population. The present study evaluated the feasibility, acceptability, and preliminary efficacy of Acceptance and Commitment Therapy for Veterans With Posttraumatic Stress Disorder (PTSD) and Tobacco Addiction (ACT-PT), which focuses on helping veterans overcome emotional challenges to quitting smoking. Methods: Veterans with current PTSD who smoked 15 or more cigarettes/day (N = 19) participated in an open trial of ACT-PT. Participants attended nine weekly individual counseling sessions and received eight weeks of nicotine patch therapy. Primary outcomes included feasibility and acceptability of the intervention, and secondary outcomes included expired-air carbon monoxide confirmed seven-day point prevalence abstinence, cravings, and PTSD symptoms. Results: The retention rate for ACT-PT was good (74%) and client satisfaction ratings were high. Participants made multiple quit attempts (M = 3.6, SD = 4.2) during the study period and were significantly more confident that they could quit smoking at three-month follow-up. At the end of treatment, 37% of participants were abstinent from smoking and 16% were abstinent at threemonth follow-up. Overall, participants reduced their smoking by 62% at the end of treatment and 43% at three-month follow-up. PTSD symptoms and smoking urges significantly decreased from baseline to the end of treatment and three-month follow-up. Conclusions: ACT-PT appears to be a promising smoking cessation treatment for veterans with PTSD. Future research should evaluate ACT-PT in a randomized controlled trial. (Journal of Dual Diagnosis, 11:50–55, 2015)
Keywords tobacco, smoking cessation, posttraumatic stress disorder, acceptance, mindfulness
Tobacco use is a substantial problem for veterans with posttraumatic stress disorder (PTSD). Veterans with PTSD have high rates of smoking (40% to 60%; Beckham et al., 1995, 1997; Davis, Bush, Kivlahan, Dobie, & Bradley, 2003) compared to the national average (19%; CDC, 2012), and their lifetime smoking quit rate is 23% (Lasser et al., 2000) compared with approximately 50% in the general population (Fiore, Hatsukami, & Baker, 2002). Individuals with PTSD who smoke frequently smoke in response to traumatic memo1Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA 2University of Massachusetts Medical School, Worcester, Massachusetts, USA 3University at Albany, State University of New York, Albany, New York, USA 4VA Connecticut Healthcare System, Newington, Connecticut, USA 5University of Connecticut School of Medicine, Farmington, Connecticut, USA Address correspondence to Megan M. Kelly, Edith Nourse Rogers Memorial Veterans Hospital, Psychology Service (116B), 200 Springs Rd., Bedford, MA 01730, USA. E-mail: [email protected]
ries, and smoking appears to temporarily reduce PTSD symptoms (Fu et al., 2007), suggesting that tobacco plays a large role in regulating the affect of individuals with PTSD who smoke. The lack of specialized tobacco treatments for individuals with PTSD (Feldner, Babson, & Zvolensky, 2007) is particularly striking, given that affect-related factors associated with PTSD are a major contributor to unsuccessful quit attempts (Fu et al., 2007). Tobacco cessation treatments that target cessation obstacles for individuals with PTSD (e.g., difficulties with affect regulation and managing smoking urges related to PTSD symptoms; Feldner et al., 2007) may be an effective means of treating tobacco use in veterans with PTSD. To support this, evidence shows that integrating tobacco cessation into PTSD treatment improves cessation outcomes compared to standard treatment (McFall et al., 2005, 2010). In response to the need for more tailored smoking cessation approaches for veterans with PTSD, we developed Acceptance and Commitment Therapy for Veterans With
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Smoking Cessation for PTSD
PTSD and Tobacco Addiction (ACT-PT). Existing smoking cessation treatments based on acceptance and commitment therapy have quit rates ranging from 22% to 35% at 12 months (Gifford et al., 2004, 2011; Hern´andez-L´opez, Luciano, Bricker, Roales-Nieto, & Monesinos, 2009; see Kelly, Latta, & Gimmestad, 2012 for a review), but none of these studies focused on individuals with mental health disorders who have more difficulty quitting. ACT-PT intensively targets motivation to quit tobacco and manage cravings related to PTSD symptoms that are important cessation obstacles for individuals with PTSD. It helps people mindfully accept and embrace smoking urges related to PTSD-related thoughts, feelings, and symptoms rather than struggle against them. ACT-PT also focuses on replacing smoking as a coping strategy for PTSD with healthier activities that are consistent with personal values. The present paper presents an overview of the ACT-PT intervention and an evaluation of the feasibility and acceptability of ACT-PT plus eight weeks of nicotine patch therapy for 19 veterans with PTSD. Secondary outcomes included preliminary data on smoking outcomes and PTSD symptoms.
METHODS Participants Inclusion criteria included the following: (a) current DSM-IV PTSD, (b) minimum score of 44 on the PTSD Checklist (PCL), (c) currently smoking at least 15 cigarettes per day, (d) competent to provide written informed consent, and (e) aged 18 and older. Exclusion criteria included any of the following: (a) unstable DSM-IV bipolar disorder, (b) lifetime DSM-IV psychotic disorder, (c) DSM-IV substance use disorder within one month of study entry, (d) unstable medical condition, (e) use of other tobacco products, (f) current use of any medications for smoking cessation, (g) clinically significant suicidality within the past year, (h) pregnant or lactating women or women of childbearing age who are not using a medically acceptable form of contraception, (i) nicotine patch allergy, and (j) any cognitive impairment (e.g., dementia, intellectual disability, or brain damage, as determined by participant report and medical record review) that would interfere with study participation. A total of 25 veterans at the Edith Nourse Rogers Memorial Veterans Hospital completed an in-person evaluation to determine eligibility for the study. Participants were referred by the local smoking cessation program (n = 14) or outpatient mental health providers (n = 2) or were self-referred (n = 9). This study was conducted in accordance with the Declaration of Helsinki and approved by the VA institutional review board. There was a complete discussion of the study with potential participants and all participants signed statements of written informed consent after this discussion. Six participants were screened out or did not participate for the following reasons: active substance use disorder (n = 1), clinically significant
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suicidality (n = 1), smoking fewer than 15 cigarettes per day (n = 1), and inability to commit to treatment (n = 3). Our initial accrual goal was 15 participants, which is consistent with the National Institutes of Drug Abuse model of behavioral therapy development (Rounsville, Carroll, & Onken, 2001), but we were able to enroll more participants within the recommended accrual goal range of 15 to 30 participants (Rounsville et al., 2001) before the end of the study period. The final sample comprised 19 participants who began treatment. All participants were in stable, long-term mental health treatment (i.e., six months or more) and no major changes in mental health treatment were made throughout the duration of the study.
Measures The Structured Clinical Interview for DSM-IV Non-Patient Version (First, Spitzer, Gibbon, & Williams, 1995, 1996) is commonly used to diagnosis psychiatric disorders, and was utilized in this study. The Fagerstr¨om Test for Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker, & Fagerstr¨om, 1991) is a six-item self-report measure of nicotine dependence. Scores range from 0 to 10, with higher scores indicating a greater level of nicotine dependence. The FTND has shown good internal consistency and test-retest reliability (Heatherton et al., 1991; Payne, Smith, McCracken, McSherry, & Antony, 1994). The Contemplation Ladder (Biener & Adams, 1991) is a continuous measure of readiness to quit smoking, displayed on an 11-point Likert scale in the form of a ladder. Higher rungs on the ladder correspond with greater motivation for change. The Contemplation Ladder has demonstrated good predictive and concurrent validity in relation to an individual’s likelihood of a serious quit attempt within six months (Biener & Adams, 1991). The Client Satisfaction Questionnaire-8 (CSQ-8; Larsen, Attkisson, Hargreaves, & Nguyen, 1979) is an eight-item scale that measures satisfaction with behavioral treatment. Scores range from 8 to 32, and higher scores reflect greater acceptability of the treatment. This scale has been used in mental health and other health centers and has acceptable internal consistency (α = .83–.93; Nguyen, Attkisson, & Stegner, 1983). The Questionnaire for Smoking Urges-Brief (QSU-Brief; Cox, Tiffany, & Christen, 2001; Tiffany & Drobes, 1991) is a 10-item measure that evaluates the structure and function of smoking urges (due to positive reinforcement and relief of negative affect). The QSU-Brief has two factors: (a) the desire to smoke due to anticipated rewarding and pleasurable effects and (b) the desire to smoke in anticipation of relief from negative affect (Tiffany & Drobes, 1991). Higher scores represent more severe smoking urges. The QSU-Brief has very good reliability for its two-factor model (α = .78–.89). 2015, Volume 11, Number 1
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Smoking outcomes included a self-report of the number of cigarettes smoked, with abstinence verified by carbon monoxide breath tests (< 8 ppm; Society for Research on Nicotine and Tobacco, 2002). Self-reports of smoking status and carbon monoxide were obtained at quit date, end of treatment, one-month follow-up, and three-month followup using the timeline follow-back method (Brown et al., 1998). The PCL (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; Weathers, Litz, Herman, Huska, & Keane, 1993) is a widely used 17-item self-report measure of PTSD symptoms. Scores on the PCL range from 17 to 85, with higher scores indicating more severe PTSD symptoms. It has excellent internal consistency (r’s = .94–.97; Blanchard et al., 1996; Weathers et al., 1993) and convergent validity with other measures of trauma (Weathers et al., 1993).
Procedures
Statistical Analyses All analyses were intention to treat, which included the full sample of 19 patients who had at least one treatment session. Primary outcomes included feasibility (i.e., treatment adherence, number of quit attempts, and readiness to change) and acceptability of the treatment. A prespecified goal for feasibility was that 70% or more of veterans would attend all sessions until the end of treatment. An additional feasibility target included 70% or more of veterans making a quit attempt during treatment. We explored whether there would be fluctuations in readiness to change as a result of participating in ACT-PT. The acceptability outcome goal included having a moderate to high level of client satisfaction on the CSQ-8 (scores ≥ 24). Secondary outcomes included number of cigarettes smoked per day and the seven-day point prevalence of smoking abstinence. We analyzed continuous outcome measures using repeated measures analysis of variance; significant results were followed up by Tukey post hoc tests.
ACT-PT Participants received nine 50-minute individual weekly sessions. The study treatment was delivered by the first author. Sessions one through four focused on the concepts of acceptance and willingness, mindfulness, cognitive defusion, and skills practice, with an emphasis on tolerance of PTSD-related triggers. Session five was the scheduled quit week. For session five, veterans were asked to quit on the day of this session and to practice acceptance and mindfulness of nicotine withdrawal symptoms and tobacco cravings. If veterans did not quit on the date of this session, they were encouraged to keep trying to quit, as well as for the rest of the treatment, and following the end of treatment. Sessions six through nine continued to focus on acceptance, willingness, and mindfulness and helped participants accept nicotine withdrawal and PTSD-related triggers without smoking. Sessions seven through nine introduced behavioral activation strategies, which included identifying activities consistent with the veterans’ values and scheduling these activities during their week in the place of smoking as an activity (e.g., spend more time with family, exercise, volunteer). Finally, session nine summarized the progress made over treatment and planning for the future, including relapse prevention and/or continuing to work on quitting smoking after the end of treatment.
Nicotine Replacement Therapy Participants received eight weeks of nicotine patch medication (21 mg for four weeks, 14 mg for two weeks, and 7 mg for two weeks). Participants received their supply of the patch on a weekly basis starting during the fifth session.
Journal of Dual Diagnosis
RESULTS Participant Characteristics As seen in Table 1, all participants were men with diagnosed PTSD and were primarily Caucasian (n = 16, 84.2%), nonHispanic (n = 19, 100%), and not married (n = 13, 68.4%). Mean age was 56 years (SD = 7.0) and participants averaged 1.2 Axis 1 disorders (SD = 1.0) in addition to their PTSD. The TABLE 1 Demographic Characteristics of Study Participants at Baseline (N = 19)
Age (years) Gender (male) Race (Caucasian) Ethnicity (Hispanic) Marital Status (Married) Number of Axis 1 Disorders1 Current Axis 1 Disorders Posttraumatic Stress Disorder Major Depressive Disorder Panic Disorder With Agoraphobia Social Anxiety Disorder Specific Phobia Obsessive-Compulsive Disorder Lifetime Axis 1 Disorders Major Depressive Disorder Panic Disorder With Agoraphobia Social Anxiety Disorder Specific Phobia Obsessive-Compulsive Disorder Alcohol Use Disorders Drug Use Disorders 1In
M
SD
56.0
7.0
1.2
addition to posttraumatic stress disorder.
n
%
19 16 0 6
100.0% 84.2% 0.0% 31.6%
19 11 4 2 4 3
100.0% 57.9% 21.1% 10.5% 21.1% 15.8%
15 5 4 4 3 16 9
78.9% 26.3% 21.1% 21.1% 15.8% 84.2% 47.4%
1.0
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Smoking Cessation for PTSD
most common lifetime disorders were major depression (n = 15, 78.9%) and alcohol use disorder (n = 16, 84.2%). Treatment Adherence
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Fourteen (74%) of 19 participants completed treatment. Participants who did not complete the study did not differ from completers on demographic characteristics or pretreatment scores. Of the 15 participants who reached the scheduled quit date, 87% (13/15) of these participants were adherent to the nicotine patch protocol either until the end of the eight-week course of the nicotine patch (6/15) or until they relapsed back to smoking prior to the end of the eight-week course (7/15). Number of Quit Attempts and Readiness to Change On average, participants tried to quit 3.6 times (SD = 4.2), and 74% (14/19) quit one time for at least 24 hours during the study period. On average, participants reported that they planned to quit smoking within 30 days and quitting smoking had a high degree of importance at baseline and at the end of the study (see Table 2). Participants were significantly more confident that they could quit smoking from baseline to the three-month follow-up, F(1, 17) = 5.41, p = .033 (see Table 2). Treatment Acceptability Client satisfaction ratings were high (CSQ-8: M = 30.5, SD = 1.7). Of those who completed treatment, 93% (13/14) indicated that ACT-PT helped them deal more effectively with tobacco dependence, were satisfied with the service they received, and would come back to the ACT-PT program if they needed help again. Cravings Means and standard deviations of measures are found in Table 2. After controlling for smoking status, smoking urges due to positive reinforcement were significantly reduced from baseline to the end of treatment, F(1, 17) = 21.68, p < .001, and the one-month follow-up, F(1, 17) = 17.14, p = .023, but not the three-month follow-up. Significant reductions in smoking urges related to relief of negative affect occurred from baseline to the end of treatment, F(1, 17) = 10.16, p = .005, the one-month follow-up, F(1, 17) = 12.42, p = .003, and the three-month follow-up, F(1, 17) = 5.34, p = .034.
TABLE 2 Means and Standard Deviations of Smoking-Related and PTSD Measures
FTND Baseline Number of Cigarettes per Day Baseline End of Treatment One-Month Follow-Up Three-Month Follow-Up Cravings: Anticipation of Pleasure Baseline End of Treatment One-Month Follow-Up Three-Month Follow-Up Cravings: Relief From Negative Affect Baseline End of Treatment One-Month Follow-Up Three-Month Follow-Up Contemplation Ladder Readiness Baseline Three-Month Follow-Up Importance Baseline Three-Month Follow-Up Confidence Baseline Three-Month Follow-Up PTSD Symptom Checklist Baseline End of Treatment One-Month Follow-Up Three-Month Follow-Up
M
SD
6.5
1.8
26.5 9.8 10.5 15.4
8.7 12.5∗ 11.8∗ 14.6∗
4.7 3.4 3.3 3.8
1.2 1.4∗ 1.4∗ 1.2
3.4 2.7 2.7 2.9
1.3 1.4∗ 1.5∗ 1.4∗
7.2 7.4
0.9 1.7
9.2 9.0
1.2 1.8
6.6 7.7
2.0 2.2∗
54.6 45.0 45.7 46.9
8.7 11.9∗ 13.0∗ 11.8∗
Note. FTND = Fagerstr¨om Test for Nicotine Dependence. ∗ Comparison with baseline levels, p < .05.
(7/19) were abstinent from smoking at the one-month followup, and 16% (3/19) were abstinent at the three-month followup. Of those who completed treatment (n = 14), 50% (7/14) were abstinent at the end of treatment, 50% (7/14) were abstinent at the one-month follow-up, and 21% (3/14) were abstinent at the three-month follow-up. Overall, participants significantly reduced the number of cigarettes per day that they smoked, F(3, 54) = 20.12, p < .001. Participants had a 62% average reduction in individual-level percentage of smoking at the end of treatment, a 62% average reduction at the one-month follow-up, and a 43% average reduction at the three-month follow-up.
PTSD Symptoms Smoking Outcomes At the end of treatment (one month after targeted quit date), 37% (7/19) of participants were abstinent from smoking, 37%
PTSD symptoms significantly decreased over time, F(3, 54) = 10.43, p < .001, including from baseline to the end of treatment (p < .001), and continued to remain significantly decreased at 2015, Volume 11, Number 1
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both the one-month follow-up (p = .001) and three-month follow-up (p = .001).
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DISCUSSION ACT-PT appears to be a feasible and acceptable smoking cessation treatment for veterans with PTSD. Ratings of treatment acceptability were high. This pilot study had a good retention rate at 74%, even for those who did not quit smoking. These results are consistent with other literature on smoking cessation interventions based on acceptance and commitment therapy, which has shown high rates of treatment acceptability and retention (e.g., Bricker, Wyszynski, Comstock, & Heffner, 2013). ACT-PT emphasizes that quitting smoking is a “journey rather than a race” and encourages participants to make several attempts until long-term abstinence is reached. To support this, most participants made several attempts to quit. We likely did not see a significant change in readiness to quit smoking from baseline to the three-month follow-up since most veterans were not abstinent at the three-month follow-up. Nevertheless, if veterans had not quit, most were prepared to make another attempt within the next 30 days. ACT-PT treatment did not result in greater ratings of the importance of quitting. However, importance scores were very high at both baseline and the three-month follow-up, and there may not have been a specific need in treatment to convince participants that quitting smoking is important. Veterans were also significantly more confident that they could quit smoking from baseline to the three-month follow-up, indicating that ACT-PT helped increase self-efficacy for quitting. Higher motivation to quit and self-efficacy are associated with a greater chance of long-term smoking abstinence (Boudreaux et al., 2012). Although our results are preliminary and obtained in a small open trial, the rates of smoking appear to be two times lower at three months than observed for veterans with PTSD in standard smoking cessation counseling, which is approximately 8%, and similar to the quit rate of integrated smoking cessation and mental health treatment for veterans with PTSD, which is roughly 14% (McFall et al., 2010). Our results are also better than those in another study of concurrent PTSD and tobacco treatment using a cognitive-behavioral smoking cessation counseling approach, which found that participants significantly decreased their cigarette use during treatment, but not at the two-month follow-up (Feldner, Smith, Monson, & Zvolensky, 2013). Participants reported significantly reduced urges to smoke due to relief of negative affect as well as reduced PTSD symptoms across all time points. Veterans were encouraged to embrace these experiences rather than avoid them, then choose actions consistent with what is important to them (e.g., spend more time with family, exercise, volunteer, garden). This emphasis within ACT-PT may have changed the Journal of Dual Diagnosis
approach that veterans took to their experiences of PTSD as well as tobacco cravings. The present study was a small uncontrolled pilot, which limits the conclusions about ACT-PT’s efficacy. In addition, veterans in the present study were in concurrent mental health treatment, which also may limit generalizability. However, mental health treatment did not touch upon tobacco cessation and was stable for at least six months, whereas significant change in the present study was seen over a nine-week period. Future randomized controlled trials with blinded assessments and multiple therapists are also necessary for evaluating the efficacy of ACT-PT. In addition, ACT-PT was only pilot tested in a male, mostly Caucasian veteran sample. Future research studies with better representation of different genders, as well as ethnic and racial backgrounds, will be important. Although preliminary, these results suggest that ACT-PT is a promising smoking cessation treatment for veterans with PTSD, was liked by veterans, and was feasible to use and evaluate in a research context. Future research is needed in order to determine how ACT-PT compares to existing smoking cessation approaches for veterans with PTSD.
ACKNOWLEDGMENTS The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. Portions of this paper were presented at the 18th and 20th annual meetings of the Society for Research on Nicotine and Tobacco (March 2012, Houston, TX, and February 2014, Seattle, WA).
DISCLOSURES Drs. Kelly, Sido, and Kalman report no financial relationships with commercial interests. In the past three years, Dr. Forsyth has received royalties from New Harbinger Publications. Dr. Ziedonis received compensation for serving on the Scientific Advisory Board for Recovery Centers of America Holdings LLC/RiverMend Healthcare, which is a for-profit entity that provides clinical services directly to patients with eating disorders, obesity, and substance use disorders. Dr. Cooney has been compensated by Pfizer, Inc. for being on the Pfizer Speaker Bureau.
FUNDING This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, VISN 1 Early Career Development Award (V1CDA2010–01), and
Smoking Cessation for PTSD
funding from the VISN 1 Mental Illness Research, Education, and Clinical Center to Megan M. Kelly.
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smoking: A systematic review. Nicotine & Tobacco Research, 9, 1071– 1084. doi:10.1080/14622200701488418 Gifford, E. V., Kohlenberg, B. S., Hayes, S. C., Antonuccio, D. O., Piasecki, M. M., Rasmussen-Hall, M., & Palm, K. M. (2004). Acceptancebased treatment for smoking cessation. Behavior Therapy, 35, 689–706. doi:10.1016/S0005-7894(04)80015-7 Gifford, E. V., Kohlenberg, B. S., Hayes, S. C., Pierson, H., Piasecki, M. P., Antonuccio, D. O., & Palm, K. M. (2011). Does acceptance and relationship focused behavior therapy contribute to bupropion outcomes? A randomized controlled trial of functional analytic psychotherapy and acceptance and commitment therapy for smoking cessation. Behavior Therapy, 42, 700–715. doi:10.1016/j.beth.2011.03.002 Heatherton, T., Kozlowski, L., Frecker, R., & Fagerstr¨om, K. (1991). The Fagerstr¨om test for nicotine dependence: A revision of the Fagerstr¨om tolerance questionnaire. British Journal of Addiction, 86, 1119–1127. doi:10.1111/j.1360-0443.1991.tb01879.x Hern´andez-L´opez, M., Luciano, M. C., Bricker, J. B., Roales-Nieto, J. G., & Monesinos, F. (2009). Acceptance and commitment therapy for smoking cessation: A preliminary study of its effectiveness in comparison with cognitive behavioral therapy. Psychology of Addictive Behaviors, 23, 723– 730. doi:10.1037/a0017632 Kelly, M. M., Latta, R. E., & Gimmestad, K. (2012). Acceptance and mindfulness-based tobacco cessation interventions for individuals with mental health disorders. Journal of Dual Diagnosis, 8, 89–98. doi:10.1080/15504263.2012.670846 Larsen, D. L., Attkisson, C. C., Hargreaves, W. A., & Nguyen, T. D. (1979). Assessment of client/patient satisfaction: Development of a general scale. Evaluation and Program Planning, 2, 197–207. doi:10.1016/01497189(79)90094-6 Lasser, K., Boyd., J. W., Woolhandler, S., Himmelstein, D. U., McCormick, D., & Bor, D. H. (2000). Smoking and mental illness: A population-based prevalence study. JAMA: Journal of the American Medical Association, 284, 2606–2610. doi:10.1001/jama.284.20.2606 McFall, M., Saxon, A. J., Malte, C. A., Chow, B., Bailey, S., Baker, D. G., . . . the CSP Study Team. (2010). Integrating tobacco cessation into mental health care for posttraumatic stress disorder: A randomized controlled trial. JAMA: Journal of the American Medical Association, 304(22), 2485– 2493. doi:10.1001/jama.2010.1769 McFall, M., Saxon, A. J., Thompson, C. E., Yoshimoto, D., Malte, C., StraitsTroster, K., . . . & Steele, B. (2005). Improving the rates of quitting smoking for veterans with posttraumatic stress disorder. American Journal of Psychiatry, 162(7), 1311–1319. doi:10.1176/appi.ajp.162.7.1311 Nguyen, T. D., Attkisson, C. C., & Stegner, B. L. (1983). Assessment of patient satisfaction: Development and refinement of a service evaluation questionnaire. Evaluation and Program Planning, 6, 299–313. Payne, T. J., Smith, P. O., McCracken, L. M., McSherry, W. C., & Antony, M. M. (1994). Assessing nicotine dependence: A comparison of the Fagerstr¨om Tolerance Questionnaire (FTQ) with the Fagerstr¨om Test for Nicotine Dependence (FTND) in a clinical sample. Addictive Behaviors, 19, 307–317. doi:10.1016/0306-4603(94)90032-9 Rounsaville, B. J., Carroll, K. M., & Onken, L. S. (2001). A stage model of behavioral therapies research: Getting started and moving from stage I. Clinical Psychology: Science and Practice, 8, 133–142. doi:10.1093/clipsy.8.2.133 Society for Research on Nicotine and Tobacco. (2002). Biochemical verification of tobacco use and cessation. Nicotine & Tobacco Research, 4(2), 149–159. doi:10.1080/14622200210123581 Tiffany, S. T., & Drobes, D. J. (1991). The development and initial validation of a questionnaire on smoking urges. British Journal of Addiction, 86, 1467–1476. doi:10.1111/j.1360-0443.1991.tb01732.x Weathers, F., Litz, B., Herman, D., Huska, J., & Keane, T. (1993, October). The PTSD Checklist: Reliability, validity, and diagnostic utility. Paper presented at the Annual Meeting of the International Society for Traumatic Stress Studies, San Antonio, TX.
2015, Volume 11, Number 1
Journal of Dual Diagnosis Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wjdd20
Acceptance and Commitment Therapy Smoking Cessation Treatment for Veterans with Posttraumatic Stress Disorder: A Pilot Study ab
a
c
Megan M. Kelly PhD , Hannah Sido PsyD , John P. Forsyth PhD , Douglas M. Ziedonis MD b
b
de
MPH , David Kalman PhD & Judith L. Cooney PhD a
Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA
b
University of Massachusetts Medical School, Worcester, Massachusetts, USA
c
University at Albany, State University of New York, Albany, New York, USA
d
VA Connecticut Healthcare System, Newington, Connecticut, USA
e
Click for updates
University of Connecticut School of Medicine, Farmington, Connecticut, USA Accepted author version posted online: 09 Dec 2014.
To cite this article: Megan M. Kelly PhD, Hannah Sido PsyD, John P. Forsyth PhD, Douglas M. Ziedonis MD MPH, David Kalman PhD & Judith L. Cooney PhD (2015) Acceptance and Commitment Therapy Smoking Cessation Treatment for Veterans with Posttraumatic Stress Disorder: A Pilot Study, Journal of Dual Diagnosis, 11:1, 50-55, DOI: 10.1080/15504263.2014.992201 To link to this article: http://dx.doi.org/10.1080/15504263.2014.992201
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JOURNAL OF DUAL DIAGNOSIS, 11(1), 50–55, 2015 C Taylor & Francis Group, LLC Copyright ISSN: 1550-4263 print / 1550-4271 online DOI: 10.1080/15504263.2014.992201
BRIEF REPORTS
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Acceptance and Commitment Therapy Smoking Cessation Treatment for Veterans with Posttraumatic Stress Disorder: A Pilot Study Megan M. Kelly, PhD,1,2 Hannah Sido, PsyD,1 John P. Forsyth, PhD,3 Douglas M. Ziedonis, MD, MPH,2 David Kalman, PhD,2 and Judith L. Cooney, PhD4,5
Objective: Veterans with PTSD smoke at rates two to three times higher than the general population, while their quit rate is less than half that of the general population. The present study evaluated the feasibility, acceptability, and preliminary efficacy of Acceptance and Commitment Therapy for Veterans With Posttraumatic Stress Disorder (PTSD) and Tobacco Addiction (ACT-PT), which focuses on helping veterans overcome emotional challenges to quitting smoking. Methods: Veterans with current PTSD who smoked 15 or more cigarettes/day (N = 19) participated in an open trial of ACT-PT. Participants attended nine weekly individual counseling sessions and received eight weeks of nicotine patch therapy. Primary outcomes included feasibility and acceptability of the intervention, and secondary outcomes included expired-air carbon monoxide confirmed seven-day point prevalence abstinence, cravings, and PTSD symptoms. Results: The retention rate for ACT-PT was good (74%) and client satisfaction ratings were high. Participants made multiple quit attempts (M = 3.6, SD = 4.2) during the study period and were significantly more confident that they could quit smoking at three-month follow-up. At the end of treatment, 37% of participants were abstinent from smoking and 16% were abstinent at threemonth follow-up. Overall, participants reduced their smoking by 62% at the end of treatment and 43% at three-month follow-up. PTSD symptoms and smoking urges significantly decreased from baseline to the end of treatment and three-month follow-up. Conclusions: ACT-PT appears to be a promising smoking cessation treatment for veterans with PTSD. Future research should evaluate ACT-PT in a randomized controlled trial. (Journal of Dual Diagnosis, 11:50–55, 2015)
Keywords tobacco, smoking cessation, posttraumatic stress disorder, acceptance, mindfulness
Tobacco use is a substantial problem for veterans with posttraumatic stress disorder (PTSD). Veterans with PTSD have high rates of smoking (40% to 60%; Beckham et al., 1995, 1997; Davis, Bush, Kivlahan, Dobie, & Bradley, 2003) compared to the national average (19%; CDC, 2012), and their lifetime smoking quit rate is 23% (Lasser et al., 2000) compared with approximately 50% in the general population (Fiore, Hatsukami, & Baker, 2002). Individuals with PTSD who smoke frequently smoke in response to traumatic memo1Edith Nourse Rogers Memorial Veterans Hospital, Bedford, Massachusetts, USA 2University of Massachusetts Medical School, Worcester, Massachusetts, USA 3University at Albany, State University of New York, Albany, New York, USA 4VA Connecticut Healthcare System, Newington, Connecticut, USA 5University of Connecticut School of Medicine, Farmington, Connecticut, USA Address correspondence to Megan M. Kelly, Edith Nourse Rogers Memorial Veterans Hospital, Psychology Service (116B), 200 Springs Rd., Bedford, MA 01730, USA. E-mail: [email protected]
ries, and smoking appears to temporarily reduce PTSD symptoms (Fu et al., 2007), suggesting that tobacco plays a large role in regulating the affect of individuals with PTSD who smoke. The lack of specialized tobacco treatments for individuals with PTSD (Feldner, Babson, & Zvolensky, 2007) is particularly striking, given that affect-related factors associated with PTSD are a major contributor to unsuccessful quit attempts (Fu et al., 2007). Tobacco cessation treatments that target cessation obstacles for individuals with PTSD (e.g., difficulties with affect regulation and managing smoking urges related to PTSD symptoms; Feldner et al., 2007) may be an effective means of treating tobacco use in veterans with PTSD. To support this, evidence shows that integrating tobacco cessation into PTSD treatment improves cessation outcomes compared to standard treatment (McFall et al., 2005, 2010). In response to the need for more tailored smoking cessation approaches for veterans with PTSD, we developed Acceptance and Commitment Therapy for Veterans With
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Smoking Cessation for PTSD
PTSD and Tobacco Addiction (ACT-PT). Existing smoking cessation treatments based on acceptance and commitment therapy have quit rates ranging from 22% to 35% at 12 months (Gifford et al., 2004, 2011; Hern´andez-L´opez, Luciano, Bricker, Roales-Nieto, & Monesinos, 2009; see Kelly, Latta, & Gimmestad, 2012 for a review), but none of these studies focused on individuals with mental health disorders who have more difficulty quitting. ACT-PT intensively targets motivation to quit tobacco and manage cravings related to PTSD symptoms that are important cessation obstacles for individuals with PTSD. It helps people mindfully accept and embrace smoking urges related to PTSD-related thoughts, feelings, and symptoms rather than struggle against them. ACT-PT also focuses on replacing smoking as a coping strategy for PTSD with healthier activities that are consistent with personal values. The present paper presents an overview of the ACT-PT intervention and an evaluation of the feasibility and acceptability of ACT-PT plus eight weeks of nicotine patch therapy for 19 veterans with PTSD. Secondary outcomes included preliminary data on smoking outcomes and PTSD symptoms.
METHODS Participants Inclusion criteria included the following: (a) current DSM-IV PTSD, (b) minimum score of 44 on the PTSD Checklist (PCL), (c) currently smoking at least 15 cigarettes per day, (d) competent to provide written informed consent, and (e) aged 18 and older. Exclusion criteria included any of the following: (a) unstable DSM-IV bipolar disorder, (b) lifetime DSM-IV psychotic disorder, (c) DSM-IV substance use disorder within one month of study entry, (d) unstable medical condition, (e) use of other tobacco products, (f) current use of any medications for smoking cessation, (g) clinically significant suicidality within the past year, (h) pregnant or lactating women or women of childbearing age who are not using a medically acceptable form of contraception, (i) nicotine patch allergy, and (j) any cognitive impairment (e.g., dementia, intellectual disability, or brain damage, as determined by participant report and medical record review) that would interfere with study participation. A total of 25 veterans at the Edith Nourse Rogers Memorial Veterans Hospital completed an in-person evaluation to determine eligibility for the study. Participants were referred by the local smoking cessation program (n = 14) or outpatient mental health providers (n = 2) or were self-referred (n = 9). This study was conducted in accordance with the Declaration of Helsinki and approved by the VA institutional review board. There was a complete discussion of the study with potential participants and all participants signed statements of written informed consent after this discussion. Six participants were screened out or did not participate for the following reasons: active substance use disorder (n = 1), clinically significant
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suicidality (n = 1), smoking fewer than 15 cigarettes per day (n = 1), and inability to commit to treatment (n = 3). Our initial accrual goal was 15 participants, which is consistent with the National Institutes of Drug Abuse model of behavioral therapy development (Rounsville, Carroll, & Onken, 2001), but we were able to enroll more participants within the recommended accrual goal range of 15 to 30 participants (Rounsville et al., 2001) before the end of the study period. The final sample comprised 19 participants who began treatment. All participants were in stable, long-term mental health treatment (i.e., six months or more) and no major changes in mental health treatment were made throughout the duration of the study.
Measures The Structured Clinical Interview for DSM-IV Non-Patient Version (First, Spitzer, Gibbon, & Williams, 1995, 1996) is commonly used to diagnosis psychiatric disorders, and was utilized in this study. The Fagerstr¨om Test for Nicotine Dependence (FTND; Heatherton, Kozlowski, Frecker, & Fagerstr¨om, 1991) is a six-item self-report measure of nicotine dependence. Scores range from 0 to 10, with higher scores indicating a greater level of nicotine dependence. The FTND has shown good internal consistency and test-retest reliability (Heatherton et al., 1991; Payne, Smith, McCracken, McSherry, & Antony, 1994). The Contemplation Ladder (Biener & Adams, 1991) is a continuous measure of readiness to quit smoking, displayed on an 11-point Likert scale in the form of a ladder. Higher rungs on the ladder correspond with greater motivation for change. The Contemplation Ladder has demonstrated good predictive and concurrent validity in relation to an individual’s likelihood of a serious quit attempt within six months (Biener & Adams, 1991). The Client Satisfaction Questionnaire-8 (CSQ-8; Larsen, Attkisson, Hargreaves, & Nguyen, 1979) is an eight-item scale that measures satisfaction with behavioral treatment. Scores range from 8 to 32, and higher scores reflect greater acceptability of the treatment. This scale has been used in mental health and other health centers and has acceptable internal consistency (α = .83–.93; Nguyen, Attkisson, & Stegner, 1983). The Questionnaire for Smoking Urges-Brief (QSU-Brief; Cox, Tiffany, & Christen, 2001; Tiffany & Drobes, 1991) is a 10-item measure that evaluates the structure and function of smoking urges (due to positive reinforcement and relief of negative affect). The QSU-Brief has two factors: (a) the desire to smoke due to anticipated rewarding and pleasurable effects and (b) the desire to smoke in anticipation of relief from negative affect (Tiffany & Drobes, 1991). Higher scores represent more severe smoking urges. The QSU-Brief has very good reliability for its two-factor model (α = .78–.89). 2015, Volume 11, Number 1
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Smoking outcomes included a self-report of the number of cigarettes smoked, with abstinence verified by carbon monoxide breath tests (< 8 ppm; Society for Research on Nicotine and Tobacco, 2002). Self-reports of smoking status and carbon monoxide were obtained at quit date, end of treatment, one-month follow-up, and three-month followup using the timeline follow-back method (Brown et al., 1998). The PCL (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996; Weathers, Litz, Herman, Huska, & Keane, 1993) is a widely used 17-item self-report measure of PTSD symptoms. Scores on the PCL range from 17 to 85, with higher scores indicating more severe PTSD symptoms. It has excellent internal consistency (r’s = .94–.97; Blanchard et al., 1996; Weathers et al., 1993) and convergent validity with other measures of trauma (Weathers et al., 1993).
Procedures
Statistical Analyses All analyses were intention to treat, which included the full sample of 19 patients who had at least one treatment session. Primary outcomes included feasibility (i.e., treatment adherence, number of quit attempts, and readiness to change) and acceptability of the treatment. A prespecified goal for feasibility was that 70% or more of veterans would attend all sessions until the end of treatment. An additional feasibility target included 70% or more of veterans making a quit attempt during treatment. We explored whether there would be fluctuations in readiness to change as a result of participating in ACT-PT. The acceptability outcome goal included having a moderate to high level of client satisfaction on the CSQ-8 (scores ≥ 24). Secondary outcomes included number of cigarettes smoked per day and the seven-day point prevalence of smoking abstinence. We analyzed continuous outcome measures using repeated measures analysis of variance; significant results were followed up by Tukey post hoc tests.
ACT-PT Participants received nine 50-minute individual weekly sessions. The study treatment was delivered by the first author. Sessions one through four focused on the concepts of acceptance and willingness, mindfulness, cognitive defusion, and skills practice, with an emphasis on tolerance of PTSD-related triggers. Session five was the scheduled quit week. For session five, veterans were asked to quit on the day of this session and to practice acceptance and mindfulness of nicotine withdrawal symptoms and tobacco cravings. If veterans did not quit on the date of this session, they were encouraged to keep trying to quit, as well as for the rest of the treatment, and following the end of treatment. Sessions six through nine continued to focus on acceptance, willingness, and mindfulness and helped participants accept nicotine withdrawal and PTSD-related triggers without smoking. Sessions seven through nine introduced behavioral activation strategies, which included identifying activities consistent with the veterans’ values and scheduling these activities during their week in the place of smoking as an activity (e.g., spend more time with family, exercise, volunteer). Finally, session nine summarized the progress made over treatment and planning for the future, including relapse prevention and/or continuing to work on quitting smoking after the end of treatment.
Nicotine Replacement Therapy Participants received eight weeks of nicotine patch medication (21 mg for four weeks, 14 mg for two weeks, and 7 mg for two weeks). Participants received their supply of the patch on a weekly basis starting during the fifth session.
Journal of Dual Diagnosis
RESULTS Participant Characteristics As seen in Table 1, all participants were men with diagnosed PTSD and were primarily Caucasian (n = 16, 84.2%), nonHispanic (n = 19, 100%), and not married (n = 13, 68.4%). Mean age was 56 years (SD = 7.0) and participants averaged 1.2 Axis 1 disorders (SD = 1.0) in addition to their PTSD. The TABLE 1 Demographic Characteristics of Study Participants at Baseline (N = 19)
Age (years) Gender (male) Race (Caucasian) Ethnicity (Hispanic) Marital Status (Married) Number of Axis 1 Disorders1 Current Axis 1 Disorders Posttraumatic Stress Disorder Major Depressive Disorder Panic Disorder With Agoraphobia Social Anxiety Disorder Specific Phobia Obsessive-Compulsive Disorder Lifetime Axis 1 Disorders Major Depressive Disorder Panic Disorder With Agoraphobia Social Anxiety Disorder Specific Phobia Obsessive-Compulsive Disorder Alcohol Use Disorders Drug Use Disorders 1In
M
SD
56.0
7.0
1.2
addition to posttraumatic stress disorder.
n
%
19 16 0 6
100.0% 84.2% 0.0% 31.6%
19 11 4 2 4 3
100.0% 57.9% 21.1% 10.5% 21.1% 15.8%
15 5 4 4 3 16 9
78.9% 26.3% 21.1% 21.1% 15.8% 84.2% 47.4%
1.0
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Smoking Cessation for PTSD
most common lifetime disorders were major depression (n = 15, 78.9%) and alcohol use disorder (n = 16, 84.2%). Treatment Adherence
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Fourteen (74%) of 19 participants completed treatment. Participants who did not complete the study did not differ from completers on demographic characteristics or pretreatment scores. Of the 15 participants who reached the scheduled quit date, 87% (13/15) of these participants were adherent to the nicotine patch protocol either until the end of the eight-week course of the nicotine patch (6/15) or until they relapsed back to smoking prior to the end of the eight-week course (7/15). Number of Quit Attempts and Readiness to Change On average, participants tried to quit 3.6 times (SD = 4.2), and 74% (14/19) quit one time for at least 24 hours during the study period. On average, participants reported that they planned to quit smoking within 30 days and quitting smoking had a high degree of importance at baseline and at the end of the study (see Table 2). Participants were significantly more confident that they could quit smoking from baseline to the three-month follow-up, F(1, 17) = 5.41, p = .033 (see Table 2). Treatment Acceptability Client satisfaction ratings were high (CSQ-8: M = 30.5, SD = 1.7). Of those who completed treatment, 93% (13/14) indicated that ACT-PT helped them deal more effectively with tobacco dependence, were satisfied with the service they received, and would come back to the ACT-PT program if they needed help again. Cravings Means and standard deviations of measures are found in Table 2. After controlling for smoking status, smoking urges due to positive reinforcement were significantly reduced from baseline to the end of treatment, F(1, 17) = 21.68, p < .001, and the one-month follow-up, F(1, 17) = 17.14, p = .023, but not the three-month follow-up. Significant reductions in smoking urges related to relief of negative affect occurred from baseline to the end of treatment, F(1, 17) = 10.16, p = .005, the one-month follow-up, F(1, 17) = 12.42, p = .003, and the three-month follow-up, F(1, 17) = 5.34, p = .034.
TABLE 2 Means and Standard Deviations of Smoking-Related and PTSD Measures
FTND Baseline Number of Cigarettes per Day Baseline End of Treatment One-Month Follow-Up Three-Month Follow-Up Cravings: Anticipation of Pleasure Baseline End of Treatment One-Month Follow-Up Three-Month Follow-Up Cravings: Relief From Negative Affect Baseline End of Treatment One-Month Follow-Up Three-Month Follow-Up Contemplation Ladder Readiness Baseline Three-Month Follow-Up Importance Baseline Three-Month Follow-Up Confidence Baseline Three-Month Follow-Up PTSD Symptom Checklist Baseline End of Treatment One-Month Follow-Up Three-Month Follow-Up
M
SD
6.5
1.8
26.5 9.8 10.5 15.4
8.7 12.5∗ 11.8∗ 14.6∗
4.7 3.4 3.3 3.8
1.2 1.4∗ 1.4∗ 1.2
3.4 2.7 2.7 2.9
1.3 1.4∗ 1.5∗ 1.4∗
7.2 7.4
0.9 1.7
9.2 9.0
1.2 1.8
6.6 7.7
2.0 2.2∗
54.6 45.0 45.7 46.9
8.7 11.9∗ 13.0∗ 11.8∗
Note. FTND = Fagerstr¨om Test for Nicotine Dependence. ∗ Comparison with baseline levels, p < .05.
(7/19) were abstinent from smoking at the one-month followup, and 16% (3/19) were abstinent at the three-month followup. Of those who completed treatment (n = 14), 50% (7/14) were abstinent at the end of treatment, 50% (7/14) were abstinent at the one-month follow-up, and 21% (3/14) were abstinent at the three-month follow-up. Overall, participants significantly reduced the number of cigarettes per day that they smoked, F(3, 54) = 20.12, p < .001. Participants had a 62% average reduction in individual-level percentage of smoking at the end of treatment, a 62% average reduction at the one-month follow-up, and a 43% average reduction at the three-month follow-up.
PTSD Symptoms Smoking Outcomes At the end of treatment (one month after targeted quit date), 37% (7/19) of participants were abstinent from smoking, 37%
PTSD symptoms significantly decreased over time, F(3, 54) = 10.43, p < .001, including from baseline to the end of treatment (p < .001), and continued to remain significantly decreased at 2015, Volume 11, Number 1
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both the one-month follow-up (p = .001) and three-month follow-up (p = .001).
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DISCUSSION ACT-PT appears to be a feasible and acceptable smoking cessation treatment for veterans with PTSD. Ratings of treatment acceptability were high. This pilot study had a good retention rate at 74%, even for those who did not quit smoking. These results are consistent with other literature on smoking cessation interventions based on acceptance and commitment therapy, which has shown high rates of treatment acceptability and retention (e.g., Bricker, Wyszynski, Comstock, & Heffner, 2013). ACT-PT emphasizes that quitting smoking is a “journey rather than a race” and encourages participants to make several attempts until long-term abstinence is reached. To support this, most participants made several attempts to quit. We likely did not see a significant change in readiness to quit smoking from baseline to the three-month follow-up since most veterans were not abstinent at the three-month follow-up. Nevertheless, if veterans had not quit, most were prepared to make another attempt within the next 30 days. ACT-PT treatment did not result in greater ratings of the importance of quitting. However, importance scores were very high at both baseline and the three-month follow-up, and there may not have been a specific need in treatment to convince participants that quitting smoking is important. Veterans were also significantly more confident that they could quit smoking from baseline to the three-month follow-up, indicating that ACT-PT helped increase self-efficacy for quitting. Higher motivation to quit and self-efficacy are associated with a greater chance of long-term smoking abstinence (Boudreaux et al., 2012). Although our results are preliminary and obtained in a small open trial, the rates of smoking appear to be two times lower at three months than observed for veterans with PTSD in standard smoking cessation counseling, which is approximately 8%, and similar to the quit rate of integrated smoking cessation and mental health treatment for veterans with PTSD, which is roughly 14% (McFall et al., 2010). Our results are also better than those in another study of concurrent PTSD and tobacco treatment using a cognitive-behavioral smoking cessation counseling approach, which found that participants significantly decreased their cigarette use during treatment, but not at the two-month follow-up (Feldner, Smith, Monson, & Zvolensky, 2013). Participants reported significantly reduced urges to smoke due to relief of negative affect as well as reduced PTSD symptoms across all time points. Veterans were encouraged to embrace these experiences rather than avoid them, then choose actions consistent with what is important to them (e.g., spend more time with family, exercise, volunteer, garden). This emphasis within ACT-PT may have changed the Journal of Dual Diagnosis
approach that veterans took to their experiences of PTSD as well as tobacco cravings. The present study was a small uncontrolled pilot, which limits the conclusions about ACT-PT’s efficacy. In addition, veterans in the present study were in concurrent mental health treatment, which also may limit generalizability. However, mental health treatment did not touch upon tobacco cessation and was stable for at least six months, whereas significant change in the present study was seen over a nine-week period. Future randomized controlled trials with blinded assessments and multiple therapists are also necessary for evaluating the efficacy of ACT-PT. In addition, ACT-PT was only pilot tested in a male, mostly Caucasian veteran sample. Future research studies with better representation of different genders, as well as ethnic and racial backgrounds, will be important. Although preliminary, these results suggest that ACT-PT is a promising smoking cessation treatment for veterans with PTSD, was liked by veterans, and was feasible to use and evaluate in a research context. Future research is needed in order to determine how ACT-PT compares to existing smoking cessation approaches for veterans with PTSD.
ACKNOWLEDGMENTS The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. Portions of this paper were presented at the 18th and 20th annual meetings of the Society for Research on Nicotine and Tobacco (March 2012, Houston, TX, and February 2014, Seattle, WA).
DISCLOSURES Drs. Kelly, Sido, and Kalman report no financial relationships with commercial interests. In the past three years, Dr. Forsyth has received royalties from New Harbinger Publications. Dr. Ziedonis received compensation for serving on the Scientific Advisory Board for Recovery Centers of America Holdings LLC/RiverMend Healthcare, which is a for-profit entity that provides clinical services directly to patients with eating disorders, obesity, and substance use disorders. Dr. Cooney has been compensated by Pfizer, Inc. for being on the Pfizer Speaker Bureau.
FUNDING This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, VISN 1 Early Career Development Award (V1CDA2010–01), and
Smoking Cessation for PTSD
funding from the VISN 1 Mental Illness Research, Education, and Clinical Center to Megan M. Kelly.
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2015, Volume 11, Number 1
