Proactive Tobacco Treatment for Smokers Using Veterans Administration Mental Health Clinics


      Veterans with a mental health diagnosis have high rates of tobacco use but encounter low rates of treatment from providers. This study tested whether a proactive tobacco treatment approach increases treatment engagement and abstinence rates in Department of Veterans Affairs mental health patients.

      Study design



      The study was performed from 2013 to 2017 and analyses were conducted in 2017. Investigators used the electronic medical record at four Veterans Administration facilities to identify patients documented as current smokers and who had a mental health clinic visit in the past 12 months.


      Patients were mailed an introductory letter and baseline survey. Survey respondents were enrolled and randomized to intervention (n=969) or control (n=969). Control participants received a list of usual Veterans Administration smoking services. Intervention participants received a motivational outreach call, multisession telephone counseling, and assistance with obtaining nicotine replacement therapy.

      Main outcome measures

      Participants completed surveys at baseline, 6 months, and 12 months after randomization. The primary outcome was self-reported 7-day abstinence from cigarettes at 12-month follow-up. Secondary outcomes included use of cessation treatment, self-reported 7-day abstinence at 6-month follow-up, and 6-month prolonged abstinence at 12-month follow-up.


      At 12 months, intervention participants were more likely to report using telephone counseling (19% vs 3%, OR=7.34, 95% CI=4.59, 11.74), nicotine replacement therapy (47% vs 35%, OR=1.63, 95% CI=1.31, 2.03), or both counseling and nicotine replacement therapy (16% vs 2%, OR=11.93, 95% CI=6.34, 22.47). Intervention participants were more likely to report 7-day abstinence (19% vs 14%, OR=1.50, 95% CI=1.12, 2.01) and prolonged 6-month abstinence (16% vs 9%, OR=1.87, 95% CI=1.34, 2.61). After adjusting for non-ignorable missingness at follow-up, the intervention effects on 7-day and prolonged abstinence remained significant (p<0.05).


      Proactive outreach was more effective than usual Veterans Administration care at increasing treatment engagement and long-term abstinence in mental health patients.

      Trial registration

      This study is registered at NCT01737281.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • U.S. DHHS
        The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General.
        U.S. DHHS, CDC, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, Atlanta, GA2014
        • Substance Abuse and Mental Health Services Administration
        Adults With Mental Illness or Substance Use Disorder Account for 40 Percent of All Cigarettes Smoked.
        Substance Abuse and Mental Health Services Administration, Rockville, MD2013
        • Schroeder S.A.
        • Morris C.D.
        Confronting a neglected epidemic: tobacco cessation for persons with mental illnesses and substance abuse problems.
        Annu Rev Public Health. 2010; 31: 297-314
        • Addington J.
        • El-Guebaly N.
        • Addington D.
        • Hodgins D.
        Readiness to stop smoking in schizophrenia.
        Can J Psychiatry. 1997; 42: 49-52
        • Etter M.
        • Mohr S.
        • Garin C.
        • Etter J.F.
        Stages of change in smokers with schizophrenia or schizoaffective disorder and in the general population.
        Schizophr Bull. 2004; 30: 459-468
        • Green M.A.
        • Clarke D.E.
        Smoking reduction and cessation: a hospital-based survey of outpatients’ attitudes.
        J Psychosoc Nurs Ment Health Serv. 2005; 43: 18-25
        • Prochaska J.
        • Rossi J.
        • Redding C.
        Depressed smokers and stage of change: implications for treatment interventions.
        Drug Alcohol Depend. 2004; 76: 143-151
        • Twyman L.
        • Bonevski B.
        • Paul C.
        • Bryant J.
        Perceived barriers to smoking cessation in selected vulnerable groups: a systematic review of the qualitative and quantitative literature.
        BMJ Open. 2014; 4: e006414
        • Rogers E.S.
        • Smelson D.A.
        • Gillespie C.C.
        • et al.
        Telephone smoking-cessation counseling for smokers in mental health clinics: a patient-randomized controlled trial.
        Am J Prev Med. 2016; 50: 518-527
        • Thorndike A.N.
        • Stafford R.S.
        • Rigotti NA
        U.S. physicians’ treatment of smoking in outpatients with psychiatric diagnoses.
        Nicotine Tob Res. 2001; 3: 85-91
        • Cohen D.J.
        • Tallia A.F.
        • Crabtree B.F.
        • Young D.M.
        Implementing health behavior change in primary care: lessons from prescription for health.
        Ann Fam Med. 2005; 3: S12-S19
        • Rogers E.
        • Sherman S.
        Tobacco use screening and treatment by outpatient psychiatrists before and after release of the American Psychiatric Association treatment guidelines for nicotine dependence.
        Am J Public Health. 2014; 104: 90-95
        • Richter K.P.
        • McCool R.M.
        • Okuyemi K.S.
        • Mayo M.S.
        • Ahluwalia J.S.
        Patients’ views on smoking cessation and tobacco harm reduction during drug treatment.
        Nicotine Tob Res. 2002; 4: S175-S182
        • Fu S.S.
        • van Ryn M.
        • Sherman S.E.
        • et al.
        Proactive tobacco treatment and population-level cessation: a pragmatic randomized clinical trial.
        JAMA Intern Med. 2014; 174: 671-677
        • Fu S.S.
        • van Ryn M.
        • Nelson D.
        • et al.
        Proactive tobacco treatment offering free nicotine replacement therapy and telephone counselling for socioeconomically disadvantaged smokers: a randomised clinical trial.
        Thorax. 2016; 71: 446-453
        • Rogers E.S.
        • Fu S.S.
        • Krebs P.
        • et al.
        Proactive outreach for smokers using VHA mental health clinics: protocol for a patient-randomized clinical trial.
        BMC Public Health. 2014; 14: 1294
        • Rogers E.S.
        • Fernandez S.
        • Kalman D.
        • Smelson D.
        • deTorrijos F.
        • Sherman S.E.
        TeleQuit Mental Health Counseling Manual.
        Department of Veterans Affairs, New York, NY2009
        • The Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff
        A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U.S. Public Health Service report.
        Am J Prev Med. 2008; 35: 158-176
      1. University of San Diego. California Tobacco Surveys. Accessed February 2018.

        • Heatherton T.F.
        • Kozlowski L.T.
        • Frecker R.C.
        • Rickert W.
        • Robinson J.
        Measuring the heaviness of smoking: Using self-reported time to the 1st cigarette of the day and number of cigarettes smoked per day.
        Br J Addict. 1989; 84: 791-800
        • Kessler R.C.
        • Green J.G.
        • Gruber M.J.
        • et al.
        Screening for serious mental illness in the general population with the K6 screening scale: results from the WHO World Mental Health (WMH) survey initiative.
        Int J Methods Psychiatr Res. 2010; 19: 4-22
        • Kroenke K.
        • Strine T.W.
        • Spitzer R.L.
        • Williams J.B.
        • Berry J.T.
        • Mokdad A.H.
        The PHQ-8 as a measure of current depression in the general population.
        J Affect Disord. 2009; 114: 163-173
        • Hughes J.R.
        • Keely J.P.
        • Niaura R.S.
        • Ossip-Klein D.J.
        • Richmond R.L.
        • Swan G.E.
        Measures of abstinence in clinical trials: Issues and recommendations.
        Nicotine Tob Res. 2003; 5: 13-25
        • Nelson D.B.
        • Partin M.R.
        • Fu S.S.
        • Joseph A.M.
        • An L.C.
        Why assigning ongoing tobacco use is not necessarily a conservative approach to handling missing tobacco cessation outcomes.
        Nicotine Tob Res. 2009; 11: 77-83
        • Little R.J.
        • Rubin D.B.
        Statistical Analysis With Missing Data.
        John Wiley & Sons, New York, NY1987
        • Ibrahim J.G.
        Incomplete data in generalized linear models.
        J Am Stat Assoc. 1990; 85: 765-769
        • McFall M.
        • Saxon A.J.
        • Malte C.A.
        • et al.
        Integrating tobacco cessation into mental health care for posttraumatic stress disorder: a randomized controlled trial.
        JAMA. 2010; 304: 2485-2493
        • Ashton M.
        • Miller C.L.
        • Bowden J.A.
        • Bertossa S.
        People with mental illness can tackle tobacco.
        Aust N Z J Psychiatry. 2010; 44: 1021-1028
        • Klee A.
        • Stacy M.
        • Rosenheck R.
        • Harkness L.
        • Tsai J.
        Interest in technology-based therapies hampered by access: a survey of veterans with serious mental illnesses.
        Psychiatr Rehabil J. 2016; 39: 173-179
        • Miller C.J.
        • McInnes D.K.
        • Stolzmann K.
        • Bauer M.S.
        Interest in use of technology for healthcare among veterans receiving treatment for mental health.
        Telemed J E Health. 2016; 22: 847-854
      2. Cinciripini P. The University of Texas MD Anderson Cancer Center Tobacco Treatment Program. Published 2017. Accessed January 7, 2018.

        • SRNT Subcommittee on Biochemical Verification
        Biochemical verification of tobacco use and cessation.
        Nicotine Tob Res. 2002; 4: 149-159
        • Pattanayak R.D.
        • Jain R.
        • Sagar R.
        Reliability of self-reported tobacco use in bipolar disorder: an exploratory study of euthymic patients visiting a tertiary care hospital in India.
        Int J Psychiatry Med. 2012; 43: 153-163
        • Sherman S.E.
        • Link A.R.
        • Rogers E.S.
        • et al.
        Smoking-cessation interventions for urban hospital patients: a randomized comparative effectiveness trial.
        Am J Prev Med. 2016; 51: 566-577