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.
