Tobacco Dependence Treatment and Organizational Change

The Department of Psychiatry has led the implementation of two “Addressing Tobacco Dependence through Organizational Change (ATTOC)” projects at the ENRM VAMC —one in outpatient primary care clinics, and one in a residential care facility for veterans with substance abuse histories who are also homeless. The first project (in primary care) is almost completed and the second project is currently underway. In both settings, the ATTOC team provides tailored interventions, including staff training, with the objective of eliminating systemic barriers to eliminating tobacco use among veterans. . Process evaluations (e.g., via focus groups) are being used in these projects to help us consider ways in which the ATTOC model needs to be adapted for use in the VA. We are also evaluating the impact of the intervention on staff knowledge, beliefs and practices as they relate to addressing tobacco use.

Experts on nicotine dependence from the Department of Psychiatry are also conducting two NIH-funded clinical trials of smoking cessation treatment. One of these trials focuses on smokers in early recovery from alcohol and drug addictions. In this study, which is nearing completion, smokers were randomly assigned to nicotine patch plus bupropion or nicotine patch plus placebo bupropion. Three papers (one published and two currently under review) report findings from this study. A second trial, in conjunction with Massachusetts General Hospital/Harvard University, is investigating the efficacy of long-term use (52 weeks) of varenicline (Chantix) for smokers with schizophrenia. In addition to evaluating medication efficacy, this study is assessing the safety of varenicline for smokers with schizophrenia and also the effect of smoking cessation on symptoms of schizophrenia.

Our partnership with the VA also includes exciting work in neurobiological manifestations of addictions. In a pilot project, we are examining the effect of alcohol abstinence on conscious and unconscious control (measured by eye movement) over reactivity to alcohol, tobacco and neutral cues. Two groups of smokers in alcohol recovery will be recruited (one of smokers with 2-4 weeks of alcohol abstinence, a second of smokers with 6-8 months of alcohol abstinence). We hypothesize that all subjects will display impaired control (both conscious and unconscious control) when presented with alcohol and smoking vs. neutral cues; however, we are believe that subjects with six to eight months of alcohol abstinence will exhibit greater control (both types) when presented with alcohol and smoking cues than their counterparts with only two to four weeks of abstinence. The results of this study will have implications for treatment plans, especially regarding the optimal timing of tobacco dependence treatment for smokers who are also recovering from alcohol addictions. Furthermore, this study will shed light on the importance of developing treatments that strengthen unconscious as well as conscious control mechanisms as a means of abetting recovery successes.