CPT-SMART for Treatment of PTSD and Cigarette Smoking

Study Overview
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Brief Summary
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Smoking is the leading cause of preventable illness, disability, and death in the United States. The rate of smoking is disproportionately higher among Veterans with posttraumatic stress disorder (PTSD). Unfortunately, smoking cessation efforts that are effective in the general population have shown limited effectiveness in smokers with PTSD. The high smoking rate and difficulty with achieving abstinence indicate a critical need to develop effective interventions for Veterans who smoke and have PTSD. The investigators' data indicate that negative emotions and trauma reminders are associated with relapse for smokers with PTSD. In this context, an ideal strategy may be to combine evidence-based PTSD treatment with intensive smoking cessation treatment to maximize quit rates. Cognitive processing therapy (CPT) is a well-established evidence-based treatment for PTSD. The investigators have successfully developed a treatment manual that combines CPT with cognitive-behavioral counseling for smoking cessation. Contingency management (CM) is another intensive behavioral treatment that has been shown to help with reducing smoking. CM provides positive reinforcers such as money to individuals misusing substances contingent upon abstinence from use. The primary goal of this study is to evaluate the efficacy of a treatment that combines CM with cognitive-behavioral smoking cessation counseling, smoking cessation medication, and CPT. Proposed is a randomized, two-arm clinical trial in which 120 Veteran smokers with PTSD will be randomized to either: 1) COGNITIVE PROCESSING THERAPY with SMOKING ABSTINENCE REINFORCEMENT THERAPY (CPT-SMART) or 2) COMBINED CONTACT CONTROL, an intervention identical to CPT-SMART in PTSD and smoking treatment, except for using payment that is not contingent on abstinence. Specific aims include: AIM 1) To evaluate the efficacy of CPT-SMART on rates of short- and long-term abstinence from cigarettes; AIM 2) To evaluate the impact of CPT-SMART on treatment engagement and utilization; and an EXPLORATORY AIM) To explore mechanisms of CPT-SMART on long-term smoking abstinence. The positive public health impact of reducing smoking among Veterans with PTSD could be enormous as it would prevent significant smoking-related morbidity and mortality.

Detailed Description
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Smoking is the leading cause of preventable illness, disability, and death in the United States. The rate of smoking is disproportionately higher among Veterans with posttraumatic stress disorder (PTSD). Unfortunately, smoking cessation efforts that are effective in the general population have shown limited effectiveness in smokers with PTSD. The high smoking rate and difficulty with achieving abstinence indicate a critical need to develop effective interventions for PTSD smokers. The investigators' data indicate that negative affect and trauma reminders are a significant antecedent of relapse for PTSD smokers. Further, despite evidence that nicotine may exacerbate PTSD symptoms, many smokers with PTSD expect that smoking helps manage their symptoms. In this context, an ideal strategy may be to combine evidence-based PTSD treatment with intensive smoking cessation treatment to maximize quit rates in this at-risk population. Cognitive processing therapy (CPT) is a well-established evidence-based treatment for PTSD. The investigators have successfully developed a treatment manual that integrates CPT with guideline-concordant cognitive-behavioral counseling for smoking cessation. Contingency management (CM) is an intensive behavioral treatment that has demonstrated efficacy for reducing smoking in a range of difficult-to-treat populations, including individuals with psychiatric disorders. CM provides positive reinforcers (e.g., vouchers, money) to individuals misusing substances contingent upon bioverified abstinence from drug use. The primary goal of the current study is to evaluate the efficacy of an intervention that combines clinic-based CM using twice weekly monitoring with salivary cotinine test strips, cognitive-behavioral smoking cessation counseling, smoking cessation medication, and evidence-based PTSD treatment. Proposed is a randomized, two-arm clinical trial in which 120 Veteran smokers with PTSD will be randomized to either: 1) COGNITIVE PROCESSING THERAPY with SMOKING ABSTINENCE REINFORCEMENT THERAPY (CPT-SMART) - an intervention that combines evidenced-based PTSD treatment with guideline-concordant cognitive-behavioral smoking cessation counseling, bupropion, and intensive behavioral therapy through CM; or 2) COMBINED CONTACT CONTROL: an intervention identical to CPT-SMART in PTSD and smoking treatment, except for using non-contingent payment (i.e., yoked CM) to control for compensation and monitoring. Specific aims include: AIM 1) To evaluate the efficacy of CPT-SMART on rates of short- and long-term abstinence from cigarettes (assessed with multiple measures including bioverified abstinence) measured at 1-week post-treatment, 4-months, and 6 months; AIM 2) To evaluate the impact of CPT-SMART on treatment engagement and utilization; and an EXPLORATORY AIM) To explore mechanisms of CPT-SMART on long-term smoking abstinence, including self-efficacy, salience of smoking, and psychiatric symptom reduction. The VA has already implemented CM for treatment of substance abuse. If shown efficacious, a combined PTSD treatment plus incentive-based approaches for smoking could be implemented into specialty PTSD programs. The positive public health impact of reducing smoking among Veterans with PTSD could be enormous as it would prevent significant smoking-related morbidity and mortality.

Official Title
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CPT-SMART for Treatment of PTSD and Cigarette Smoking

Conditions
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Smoking, Stress Disorders, Post-Traumatic

Intervention / Treatment
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* Behavioral: Smoking Cessation Cognitive Behavioral Therapy (CBT)
* Drug: Bupropion
* Behavioral: Cognitive Processing Therapy
* Behavioral: Smoking Abstinence Reinforcement Therapy
* Behavioral: Yoked Contingency Management


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Is Veteran Is between the ages of 18 and 80 Smokes ten or more cigarettes per day for the past year Has been smoking for at least the past year Meets criteria for current PTSD Speaks and writes English Is willing to attempt smoking cessation and trauma-focused psychotherapy Exclusion Criteria: Has had myocardial infarction in the past 6 months Uses other forms of nicotine that he/she is unwilling to stop Is pregnant Has a primary psychotic disorder Has a current substance use disorder other than tobacco use disorder Has a contraindication to bupropion use with no medical clearance to use it Is unwilling to use bupropion Is receiving other behavioral smoking counseling or trauma-focused therapy or plans to do so during the study period Is currently imprisoned or in psychiatric hospitalization

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Randomized, two-arm clinical trial
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: CPT-SMART<br>COGNITIVE PROCESSING THERAPY with SMOKING ABSTINENCE REINFORCEMENT THERAPY (CPT-SMART) - an intervention that combines evidence-based PTSD treatment with guideline-concordant cognitive-behavioral smoking cessation counseling, bupropion, and intensive behavioral therapy through CM. | Behavioral: Smoking Cessation Cognitive Behavioral Therapy (CBT)<br>* 12 sessions of cognitive behavioral therapy for smoking cessation, designed to help participants prepare for quitting smoking, make a quit attempt, and stay quit from smoking.<br>* Other names: CBT;Drug: Bupropion<br>* All medically eligible participants will be prescribed bupropion to begin 7 days before the quit date and continued through 12 weeks post-quit. Participants will be scheduled to begin at 150mg/day of bupropion for at least 3 days before titrating up to 300mg/day dose of bupropion.<br>* Other names: Zyban;Behavioral: Cognitive Processing Therapy<br>* 12 sessions of CPT, which is a well-established trauma-focused psychotherapy for PTSD that has demonstrated efficacy and effectiveness in Veterans.<br>* Other names: CPT;Behavioral: Smoking Abstinence Reinforcement Therapy<br>* Monetary reinforcement for smoking abstinence that is bioverified by breath carbon monoxide and saliva samples.<br>* Other names: SMART;|
| Active Comparator: Combined Contact Yoked Control<br>COMBINED CONTACT YOKED CONTROL (CCYC) - an intervention that is identical to CPT-SMART for PTSD and smoking treatment, except for using non-contingent payment (i.e., yoked CM) to control for compensation and monitoring. | Behavioral: Smoking Cessation Cognitive Behavioral Therapy (CBT)<br>* 12 sessions of cognitive behavioral therapy for smoking cessation, designed to help participants prepare for quitting smoking, make a quit attempt, and stay quit from smoking.<br>* Other names: CBT;Drug: Bupropion<br>* All medically eligible participants will be prescribed bupropion to begin 7 days before the quit date and continued through 12 weeks post-quit. Participants will be scheduled to begin at 150mg/day of bupropion for at least 3 days before titrating up to 300mg/day dose of bupropion.<br>* Other names: Zyban;Behavioral: Cognitive Processing Therapy<br>* 12 sessions of CPT, which is a well-established trauma-focused psychotherapy for PTSD that has demonstrated efficacy and effectiveness in Veterans.<br>* Other names: CPT;Behavioral: Yoked Contingency Management<br>* Participants in the yoked control will receive the monetary reinforcement of their yoked participant regardless of smoking abstinence or session attendance.<br>* Other names: Control CM;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of participants whose self-report of 7 day point prevalence abstinence from smoking is bioverified | 7-day point prevalence abstinence is defined as no smoking in the prior 7 days. | 6 month follow-up | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of participants whose self-report of 30 day point prevalence abstinence from smoking is bioverified | 30-day point prevalence abstinence is defined as no smoking in the prior 30 days. | 6 month follow-up | 
| Number of participants whose self-report of 7 day point prevalence abstinence from smoking is bioverified | 7-day point prevalence abstinence is defined as no smoking in the prior 7 days. | 4 month follow-up | 
| Number of participants whose self-report of 30 day point prevalence abstinence from smoking is bioverified | 30-day point prevalence abstinence is defined as no smoking in the prior 30 days. | 4 month follow-up | 
| Number of participants who self-report prolonged abstinence | Prolonged abstinence is defined as 30 days abstinent. | 4 month follow-up | 
| Number of participants who self-report prolonged abstinence | Prolonged abstinence is defined as 30 days abstinent. | 6 month follow-up | 
| Number of participants who self-report early abstinence | Early abstinence is defined as 2 consecutive sessions abstinent in first month of quit attempt. | Measured at the post-treatment visit (2 weeks after treatment completed) | 
| Number of participants who attended eight or more sessions of combined CPT and CBT for smoking | Those who complete eight or more treatment sessions will be considered to have had an adequate treatment dose. | Measured at the post-treatment visit (2 weeks after treatment completed) | 
| Number of sessions attended by participants | The average number of treatment sessions attended by participants in each group will be considered a measure of treatment engagement. | Measured at the post-treatment visit (2 weeks after treatment completed) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Stress Disorders, Post-Traumatic, Smoking