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Calhoun P.S.,Durham Veterans Affairs Medical Center | Calhoun P.S.,Duke University | Calhoun P.S.,Veterans Affairs Mid Atlantic Region Mental Illness Research | Calhoun P.S.,Veterans Affairs Center for Health Services Research in Primary Care | And 27 more authors.
Journal of Substance Abuse Treatment | Year: 2016

Introduction The primary objective of this project was to examine the effectiveness of an Internet-based smoking cessation intervention combined with a tele-health medication clinic for nicotine replacement therapy (NRT) compared to referral to clinic-based smoking cessation care. Methods A total of 413 patients were proactively recruited from the Durham VA Medical Center and followed for 12 months. Patients were randomized to receive either a referral to VA specialty smoking cessation care (control) or to the Internet intervention and tele-health medication clinic. Primary outcomes included (1) intervention reach, (2) self-reported 7-day point prevalence abstinence rates at 3 months and 12 months, and 3) relative cost-effectiveness. Results Reach of the Internet intervention and use of smoking cessation aids were significantly greater compared to the control. At 3 months-post randomization, however, there were no significant differences in quit rates: 17% (95% CI: 12%–23%) in the Internet-based intervention compared to 12% (95% CI: 8%–17%) in the control arm. Similarly, there were no differences in quit rates at 12 months (13% vs. 16%). While costs associated with the Internet arm were higher due to increased penetration and intensity of NRT use, there were no statistically significant differences in the relative cost effectiveness (e.g., life years gained, quality adjusted life years) between the two arms. Conclusions Current results suggest that using an electronic medical record to identify smokers and proactively offering smoking cessation services that are consistent with US Public Health Guidelines can significantly reduce smoking in veterans. Novel interventions that increase the reach of intensive treatment are needed to maximize quit rates in this population. © 2016


Beckham J.C.,Durham Veterans Affairs Medical Center | Beckham J.C.,Veterans Affairs Mid Atlantic Region Mental Illness Research | Beckham J.C.,Duke University | Calhoun P.S.,Durham Veterans Affairs Medical Center | And 11 more authors.
Nicotine and Tobacco Research | Year: 2013

Introduction: Retrospective research suggests smokers with posttraumatic stress disorder (PTSD) lapse more quickly after their quit date. Ecological momentary assessment (EMA) research is needed to confirm the presence of early smoking lapse in PTSD and form conceptualizations that inform intervention. Methods: Smokers with (n = 55) and without (n = 52) PTSD completed alarm-prompted EMA of situational and psychiatric variables the week before and after a quit date, and self-initiated EMA following smoking lapses. Blood samples at baseline and on the quit date allowed assessment of dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEA(S)). Results: PTSD was related to shorter time to lapse (hazard ratio [HR] = 1.677, 95% CI: 1.106-2.544). Increased smoking abstinence self-efficacy was related to longer time to lapse (HR = 0.608, 95% CI: 0.430-0.860). Analyses of participants' real-time reports revealed that smokers with PTSD were more likely to attribute first-time lapses to negative affect (X12 = 5.412, p =.020), and trauma reminders (Fisher's exact p =.003**). Finally, the quit date decrease in DHEA(S) was related to shorter time to lapse (HR = 1.009, 95% CI: 1.000-1.018, p <.05). Conclusions: Results provide evidence of shorter time to first smoking lapse in PTSD, and add to evidence that early lapse occasions are more strongly related to trauma reminders, negative affect, and cravings in smokers with PTSD.


Dennis P.A.,Durham Veterans Affairs Medical Center | Dennis P.A.,Duke University | Watkins L.L.,Durham Veterans Affairs Medical Center | Calhoun P.S.,Durham Veterans Affairs Medical Center | And 10 more authors.
Psychosomatic Medicine | Year: 2014

Objective: Posttraumatic stress disorder (PTSD) has been linked to reduced heart rate variability (HRV), which is in turn a risk factor for cardiovascular disease and death. Although hyperarousal and anxiety are thought to underlie this association, behavioral health risks, including smoking, alcohol dependence, obesity, and sleep disturbance, represent potential mechanisms linking PTSD and HRV. Methods: To test this hypothesis, short-term laboratory-based and 24-hour ambulatory measures of HRV were collected from 227 young adults (18-39 years), 107 of whom were diagnosed as having PTSD. Latent variable modeling was used to assess the relationship of PTSD symptoms with HRV along with potential behavioral health mediators. Results: PTSD symptoms were associated with reduced HRV (A = -0.21, p = .002). However, this association was reduced in models that adjusted for cigarette consumption and history of alcohol dependence and was rendered nonsignificant in a model adjusting for sleep disturbance. Independent mediation effects were deemed significant via bootstrapping analysis. Together, the three behavioral health factors (cigarette consumption, history of alcohol dependence, and sleep disturbance) accounted for 94% of the shared variance between PTSD symptoms and HRV. Abdominal obesity was not a significant mediator. Conclusions: These results indicate that behavioral factorsVspecifically smoking, alcohol overuse, and sleep disturbanceVmediate the association between PTSD and HRV-based indices of autonomic nervous system dysregulation. Benefits from psychiatric and psychological interventions in PTSD may therefore be enhanced by including modification of health behaviors. Copyright © 2014 by the American Psychosomatic Society.


Dennis P.A.,Durham Veterans Affairs Medical Center | Dennis P.A.,Duke University | Weinberg J.B.,Durham Veterans Affairs Medical Center | Weinberg J.B.,Duke University | And 11 more authors.
Journal of Psychosomatic Research | Year: 2016

Objective: Posttraumatic stress disorder (PTSD) has been linked to chronic inflammation, a condition that poses a risk for cardiovascular disease. Attenuated vagal activity has been proposed as a potential mediator of PTSD and inflammation, although associated behavioral health risks-namely cigarette smoking and alcohol dependence-might also account for that link. Methods: Inflammation was quantified by fasting serum concentrations of C-reactive protein (CRP), tumor necrosis factor (TNF)-α, interleukin (IL)-10, and thymus- and activation-regulated chemokine (TARC)/CCL17 collected from 85 participants with PTSD and 82 without PTSD. Latent variable modeling was used to assess the relationship between PTSD symptom severity and inflammation along with potential mediators vagal activity (respiratory sinus arrhythmia; RSA), smoking status, and lifetime alcohol dependence. Results: PTSD symptom severity was associated with increased inflammation (β = .18, p = .02). However, this association was reduced in models that adjusted for RSA, smoking status, and lifetime alcohol dependence. Independent mediation effects were deemed significant via bootstrapping analyses. Together, RSA, smoking status, and lifetime alcohol dependence accounted for 95% of the effect of PTSD symptom severity on inflammation. Conclusion: Although RSA accounted for a modest proportion of the association between posttraumatic stress and pro-inflammatory responses, behavioral factors-specifically cigarette smoking and alcohol dependence-proved to be larger mediators. The benefits of PTSD treatment may be enhanced by additional interventions aimed at modifying these health behaviors. © 2015.


Dennis P.A.,Durham Veterans Affairs Medical Center | Ulmer C.S.,Durham Veterans Affairs Medical Center | Ulmer C.S.,Veterans Affairs Center for Health Services Research in Primary Care | Ulmer C.S.,Duke University | And 11 more authors.
Journal of Psychosomatic Research | Year: 2014

Objectives: Posttraumatic stress disorder (PTSD) has been linked to dyslipidemia, which is a major risk factor for coronary artery disease. Although this link is thought to reflect response to heightened stress, behavioral health risks, including smoking, alcohol dependence, and poor sleep quality, may mediate the relationship between PTSD and dyslipidemia. Methods: To test this hypothesis, serum lipid levels were collected from 220 young adults (18-39 years old), 103 of whom were diagnosed with PTSD. Results: PTSD and associated depressive symptoms were negatively related to high-density lipoprotein cholesterol (HDL-C), p=.04, and positively related to triglyceride (TG) levels, p=.04. Both associations were mediated by cigarette consumption and poor sleep quality, the latter of which accounted for 83% and 93% of the effect of PTSD and depression on HDL-C and TG, respectively. Conclusions: These results complement recent findings highlighting the prominence of health behaviors in linking PTSD with cardiovascular risk. © 2014.


Dennis P.A.,Durham Veterans Affairs Medical Center | Dennis P.A.,Duke University | Kimbrel N.A.,Durham Veterans Affairs Medical Center | Kimbrel N.A.,Duke University | And 12 more authors.
Addictive Behaviors | Year: 2016

Background: Individuals with posttraumatic stress disorder (PTSD) are more likely to smoke and more likely to relapse following a quit attempt than individuals without PTSD. Thus, there is a significant need to study promising interventions that might improve quit rates for smokers with PTSD. One such intervention, supplemental nicotine patch-preloading, entails the use of nicotine replacement therapy prior to quitting.Objective. The objective of this study was to conduct a randomized controlled trial of the efficacy of supplemental nicotine patch-preloading among smokers with PTSD. We hypothesized that, relative to participants in the placebo condition, participants in the nicotine patch-preloading condition would: (1) smoke less and experience reduced craving for cigarettes during the nicotine patch-preloading phase; (2) experience less smoking-associated relief from PTSD symptoms and negative affect during the preloading phase; and (3) exhibit greater latency to lapse, and higher short- and long-term abstinence rates. Methods: Sixty-three smokers with PTSD were randomized to either nicotine or placebo patch for three weeks prior to their quit date. Ecological momentary assessment was used to assess craving, smoking, PTSD symptoms, and negative affect during the preloading period. Results: Nicotine patch-preloading failed to reduce smoking or craving during the preloading phase, nor was it associated with less smoking-associated relief from PTSD symptoms and negative affect. Moreover, no differences were observed between the treatment conditions for time to lapse, 6-week abstinence, or 6-month abstinence. Conclusions: The findings from the present research suggest that supplemental nicotine patch-preloading is unlikely to substantially enhance quit rates among smokers with PTSD. © 2015.


Carpenter V.L.,Durham Veterans Affairs Medical Center | Hertzberg J.S.,Durham Veterans Affairs Medical Center | Hertzberg J.S.,Institute of Medical Research | Kirby A.C.,Durham Veterans Affairs Medical Center | And 20 more authors.
Journal of Clinical Psychiatry | Year: 2015

Introduction: Smoking rates are 80% among persons who are homeless, and these smokers have decreased odds of quitting smoking. Little is known about relapse rates among homeless smokers. More information is needed regarding both quit rates and innovative methods to treat smoking cessation among homeless smokers. Web-based contingency management (CM) approaches have been found helpful in reducing smoking among other difficultto-treat smoker populations but have been generally limited by the need for computers or frequent clinic-based carbon monoxide (CO) monitoring. This open pilot study builds on a web-based CM approach by evaluating a smartphone-based application for CM named mobile CM (mCM). The study was conducted from January 1, 2013-April 15, 2014. Method: Following a 1-week training period, 20 homeless veteran smokers (≥ 10 cigarettes daily for 1 year or more and a CO baseline level ≥ 10 ppm) participated in a multicomponent smoking cessation intervention including 4 weeks of mCM. All smokers received 4 smoking cessation counseling sessions, nicotine replacement, and bupropion (if medically eligible). Participants could earn up to $815 ($480 for mCM, $100 for CO readings showing abstinence [ie, 6 ppm or less] at posttreatment and follow-up, and $35 for equipment return). Results: Mean compensation for the mCM component was $286 of a possible $480. Video transmission compliance was high during the 1-week training (97%) and the 4-week treatment period (87%). Bioverified 7-day point prevalence abstinence was 50% at 4 weeks. Follow-up bioverified single assessment point prevalence abstinence was 55% at 3 months and 45% at 6 months. Conclusions: Results of this open pilot study suggest that mCM may be a useful adjunctive smoking cessation treatment component for reducing smoking among homeless veterans. © 2015 Physicians Postgraduate Press, Inc.


Hertzberg J.S.,Durham Veterans Affairs Medical Center | Hertzberg J.S.,Institute of Medical Research | Carpenter V.L.,Durham Veterans Affairs Medical Center | Kirby A.C.,Durham Veterans Affairs Medical Center | And 16 more authors.
Nicotine and Tobacco Research | Year: 2013

Introduction: Smokers with posttraumatic stress disorder (PTSD) smoke at higher prevalence rates and are more likely to relapse early in a quit attempt. Innovative methods are needed to enhance quit rates, particularly in the early quit period. Webbased contingency-management (CM) approaches have been found helpful in reducing smoking among other difficult-to-treat smoker populations but are limited by the need for computers. This pilot study builds on the web-based CM approach by evaluating a smartphone-based application for CM named mobile CM (mCM). Methods: Following a 2-week training period, 22 smokers with PTSD were randomized to a 4-week mCM condition or a yoked (i.e., noncontingent 4-week mCM condition). All smokers received 2 smoking cessation counseling sessions, nicotine replacement, and bupropion. Participants could earn up to $690 ($530 for mCM, $25.00 for assessments and office visits [up to 5], and $35.00 for equipment return). The average earned was $314.00. Results: Compliance was high during the 2-week training period (i.e., transmission of videos) (93%) and the 4-week treatment period (92%). Compliance rates did not differ by group assignment. Four-week quit rates (verified with CO) were 82% for the mCM and 45% for the yoked controls. Three-month self-report quit rates were 50% in the mCM and 18% in the yoked controls. Conclusions: mCM may be a useful adjunctive smoking cessation treatment component for reducing smoking among smokers with PTSD, particularly early in a smoking quit attempt.


Dedert E.A.,Durham Veterans Affairs Medical Center | Dedert E.A.,Veterans Affairs Mid Atlantic Region Mental Illness Research | Dedert E.A.,Duke University | Dennis P.A.,Durham Veterans Affairs Medical Center | And 12 more authors.
Nicotine and Tobacco Research | Year: 2014

Introduction: Smokers with posttraumatic stress disorder (PTSD) tend to lapse more quickly following a quit attempt, which might be explained by changes in PTSD symptoms during a quit attempt. The present study examines changes in PTSD symptoms, negative affect, and craving before and during a quit attempt. Methods: Participants in this study were 52 smokers with PTSD who completed random-alarm ecological momentary assessments of PTSD symptoms, negative affect, cigarette craving, and smoking behavior throughout a prequit phase of ad hoc smoking, a phase of abstinence from smoking, and a postlapse phase. Results: Relative to the prequit phase, the abstinent phase was marked by decreases in PTSD reexperiencing, avoidance, and numbing clusters (ps ≤ .01). The odds of PTSD symptom or negative affect variability from one reading in the ecological momentary assessment (EMA)to the next reading was decreased in PTSD reexperiencing, avoidance, and numbing clusters (ps ≤ .02). Smoking cravings were also mildly decreased in the abstinent and postlapse phases (ps < .01), although some cravings in both phases were rated at the maximum intensity. Increased craving was predicted by the previous EMA reading of PTSD symptoms. Conclusions: Results suggested that smoking abstinence is not associated with exacerbation of PTSD symptoms, but PTSD symptoms during abstinence were related to craving levels during the quit attempt.

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