| | Smoking Among Veterans With Multiple Sclerosis: Prevalence Correlates, Quit Attempts, and Unmet Need for ServicesPreliminary data were presented to the Consortium of Multiple Sclerosis Centers, June 1–3, 2006, Scottsdale, AZ. Abstract Turner AP, Kivlahan DR, Kazis LE, Haselkorn JK. Smoking among veterans with multiple sclerosis: prevalence, correlates, quit attempts, and unmet need for services. ObjectiveTo describe the prevalence and correlates of smoking as well as quit attempts and unmet need for smoking cessation services in a national sample of veterans with multiple sclerosis (MS). DesignCross-sectional cohort study linking computerized medical record information to mailed survey data from 1999. SettingVeterans Health Administration (VHA). ParticipantsSixty-four percent (2994/4685) of veterans with MS who received services in VHA and also returned survey questionnaires, as well as a 20% random subsample (n=569) who completed a more extensive assessment of smoking. InterventionsNot applicable. Main Outcome MeasuresItems assessing smoking, quit attempts, and unmet need for smoking services. ResultsAmong all survey respondents with MS, 28.5% (95% confidence interval [CI], 26.9–30.2) endorsed current smoking. Of extended survey respondents, 54.5% (95% CI, 46.6–62.1) reported a quit attempt in the past year, and 59.0% (95% CI, 51.1–66.4) reported not getting needed services for smoking in the past year. In fully adjusted logistic regression, smoking was associated with younger age, lower levels of education, being unmarried, higher levels of physical pain, and poorer mental health. A quit attempt was associated with higher levels of education and greater pain intensity. ConclusionsSmoking among veterans with MS is common, with rates similar to those for other veterans. There is substantial need for cessation services. Cessation interventions should address correlates of smoking including pain, poorer mental health, and social isolation. MULTIPLE SCLEROSIS (MS) is a chronic degenerative disorder of the central nervous system affecting as many as 350,000 persons in the United States.1 It is associated with a host of unpredictable and disabling symptoms that include, but are not limited to, sensory and motor loss, fatigue, difficulties with balance and sexual functioning, pain, cognitive impairment, and depression.2, 3, 4, 5 MS is typically diagnosed between the ages of 20 and 40 years, and because most people have a relatively normal lifespan, they usually have a prolonged course of illness.4, 6 Smoking is the leading cause of preventable death in the United States and is responsible for over 438,000 deaths annually, as well as 5.5 million years of potential life loss, and over $92 billion in annual health-related losses.7 Tobacco use is associated with extensive health consequences, including an increased risk of numerous cancers, cerebrovascular disease, coronary heart disease, reduced bone density, and chronic obstructive pulmonary disease.8 Increasing evidence suggests a link between smoking and disease process in MS. In a large general population sample of over 22,000 people in Norway, the risk of developing MS was significantly higher among those who had ever smoked versus those who had never smoked.9 Similar results have been found in 2 large longitudinal studies of women’s health. In both instances, smoking was associated with an increased likelihood of later receiving a diagnosis of MS.10, 11 Results of large epidemiologic studies have also reported that the risk of MS increases with both the frequency and duration of tobacco use.10, 11, 12 Finally, recent evidence suggests that among people with a relapsing-remitting MS, smokers are more than 3 times as likely to develop a secondary-progressive disease course.13 In addition, smoking may exacerbate other medical problems commonly experienced by individuals with MS, or contribute to additional impairment and disability. For example, pulmonary difficulties may be compounded by chronic bronchitis, mobility limitations increased with stroke, and urinary function additionally compromised by bladder or kidney cancer.14 Smoking may also prolong the impact of decubitus ulcers by compromising wound healing.15 Existing evidence suggests that smoking status is not assessed in many medical visits, and cessation counseling for current smokers occurs in less than a quarter of all encounters.16, 17 Almost nothing is known about the overall prevalence of smoking in MS, despite the fact that it is an identified risk factor for disease onset and burden. Little is also known about the extent to which people with MS are offered cessation services. This is unfortunate because smoking cessation services as brief as 3 minutes delivered during the course of a routine clinic visit have been shown to be effective in reducing rates of smoking.18, 19, 20 Interventions that are timely and effective significantly reduce overall smoking-related disease and are highly cost effective.21, 22, 23, 24 Furthermore, repeated intervention has been shown to improve outcomes, as does repetition by multiple treatment providers and providers of different disciplines.25 As a result, assessing smoking status and providing brief intervention represents an important opportunity for rehabilitation professionals to reduce disability associated with MS, as well as improve overall health. The current study has 3 purposes. It estimates the prevalence of smoking in a large national sample of veterans with MS, examines factors associated with an increased likelihood of smoking, and explores quit attempts and unmet need for smoking cessation services. Methods  Participants Potential participants were first drawn from the Veterans Affairs (VA) MS National Data Repository, a database containing information on all veterans receiving MS-related health care services within Veterans Health Administration from 1998 to 2004. The repository is updated periodically, but at the time of the data extraction for this study, it contained 32,009 unique cases. To reduce inaccurate ascertainment due to coding errors, people were included in a final target population only if they met one or more of the following 4 criteria: (1) they had an inpatient hospitalization for MS (hospitalization with diagnostic code 340 for MS, according to the International Classification of Diseases, 9th Revision [ICD]), (2) they had received a disease modifying agent (interferon 1a, interferon 1b, or glatiramer acetate) used only to treat MS, (3) they were VA service connected for MS (the diagnosis had been confirmed through a medical review process for purposes of VA reimbursement of services), or (4) they had at least 1 outpatient encounter for which the primary ICD diagnosis code was 340 during each year in which they received some VA medical service, or they had a similarly coded inpatient stay. The process of identifying a target population within the VA MS National Data Repository by means of a search algorithm has been validated by chart review in previous work and has been shown to be an effective means of eliminating people who do not have MS.26 A total of 17,470 veterans were included in the target population. Information on persons in the target population was then linked to data from the VA Office of Quality and Performance 1999 Large Health Survey (LHS).27 The LHS was conducted to establish the health status and health behavior patterns of a nationally representative sample of veterans receiving care across the VA health care system. The survey contained a core set of questions and 5 modules that were each randomly administered to 20% of the overall sample. Information from the health behavior module (that contained additional questions about smoking and smoking services) is included in the present study. The overall LHS was returned by 877,775 of 1.4 million enrollees who were mailed surveys (response rate, 63.1%). Similarly, among people with MS in the target population, the LHS was returned by 2994 of 4685 enrollees who were mailed surveys (response rate, 63.9%). A 20% random subsample of respondents (n=569) completed the additional module containing an extended assessment of smoking. All procedures were approved by the University of Washington Human Subjects Review Committee, and the VA Office of Quality and Performance approved use of LHS data. Measures Smoking We measured cigarette use with a question adapted from the Behavioral Risk Factors Surveillance System.28 Participants were asked: “Do you now smoke cigarettes every day, some days, or not at all?” Responses were dichotomized to reflect the presence or absence of current smoking. The extended smoking survey also included a question examining the quantity of use: “On the average, about how many cigarettes a day do you smoke?” Response options ranged from 1 (none) to 5 (more than 40). The extended survey also included the dichotomously coded question: “In the past 12 months, have you quit smoking for 1 day or longer?” and a question addressing unmet need for smoking services: “In the past 12 months, how often did you get the services that you needed from your VA providers about quitting smoking or other tobacco use?” Response options ranged from 1 (never) to 4 (always). Responses were dichotomized such that a response of “never” indicated an unmet need. Demographic information Sex, race (white vs nonwhite), education level (high school or less vs more than high school), marital status (currently married vs all other), and living alone (yes vs no) were all obtained from the LHS. Age in years at the time of the survey was obtained from the VA MS National Data Repository. Physical functioning We measured physical functioning using the 10-item physical functioning scale of the Veteran Rand 36-Item Health Survey (VR-36), which is adapted from the Rand Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), version 1.0.27, 29 Participants were asked to rate to what extent health limits physical activities such as “walking one block” and “bathing or dressing yourself” ranging from 1 (yes, limited a lot) to 3 (no, not limited at all). Item responses were summed to produce a VR-36 physical functioning raw scale score (range, 10–30), with higher scores reflecting better physical functioning. The SF-36 is widely used and has been validated for use with people with MS.30, 31, 32 Internal consistency of this scale in the current sample was excellent (α=.95). Pain Pain was measured using the bodily pain item from the bodily pain scale of the VR-36.27, 29 Participants were asked to rate how much bodily pain they had experienced during the past 4 weeks, ranging from 1 (none) to 6 (very severe). Mental health Mental health was measured using the 5-item mental health scale of the VR-36.27, 29 Participants were asked to respond to questions about their mental health, such as “have you felt downhearted and blue” and “have you been a nervous person” in the past 4 weeks, with values ranging from 1 (all of the time) to 6 (none of the time). Item responses were summed and in some instances reverse scored to produce a VR-36 mental health raw scale score ranging from 5 to 30. Higher scores reflected better mental health. Internal consistency of this scale in the current sample was good (α=.86). Data Analysis Strategy We first examined the dataset to determine the extent to which the final study sample was representative of the larger population of veterans with MS using age, sex, and race variables available on all people in the repository. Selection bias (whether a person was or was not sent a survey) and response bias (whether a person did or did not return a survey) was examined for these 3 variables. The prevalence of current smoking, as well as unmet need for smoking cessation services and quit attempts, was estimated using simple proportions and 95% confidence intervals (CIs). Logistic regression was used to identify correlates of smoking, unmet need for services, and quit attempts. First, we conducted a series of individual univariate logistic regression analyses to examine the association between smoking and each potential demographic correlate (age, sex, race, education level, marital status, living alone) and health status correlate (pain intensity, physical functioning, mental health). All variables that showed a significant relationship at a univariate level were then included simultaneously in a final multivariate model. We also used logistic regression to examine correlates of unmet need for smoking cessation services and quit attempts using an identical sequence of univariate analyses followed by the creation of a final multivariate model. In this second instance, the sample was limited to persons who endorsed smoking and who completed the extended tobacco survey, which contained additional smoking questions. Results Comparability of the Study Sample Selection bias To determine if persons who were mailed the LHS survey were representative of the larger MS target population, the 2 groups were compared on sex, race, and age. There were no sex differences between people who were or were not mailed surveys, but surveys were more likely to be received by nonwhites (39.3% vs 34.3%, χ1,N=10,8732 test=16.21, P<.001). Persons who were mailed surveys were significantly older than those who did not (mean ± standard deviation [SD], 54.19±12.60y vs 52.78±13.05y, respectively; F1,16,944=40.06, P<.001), although the difference of a little over a year was small. Response bias Similarly, to determine if persons who returned the LHS survey differed from those who did not, these 2 groups were also compared on sex, race, and age. There were no differences in survey response by sex or race, but persons who returned surveys were on average older than those who did not (mean, 55.30±12.22y vs 52.18±13.03y, respectively; F1,4633=66.23, P<.001). Finally, among persons who returned the LHS survey, those who received the module containing the extended assessment of smoking did not differ from those who did not receive it on sex, race, or age. Prevalence of Smoking Among total survey respondents with MS, 28.5% (95% CI, 26.9–30.2) endorsed any current smoking and 22.0% (95% CI, 20.5–23.6) reported they smoked every day. Of extended survey respondents, 20.1% (95% CI, 17.0–23.7) reported smoking 10 or more cigarettes per day and 7.2% (95% CI, 5.4–9.7) reported smoking 21 or more cigarettes per day (table 1). Correlates of Smoking Multivariate logistic regression identified several variables associated with smoking. Age (adjusted odds ratio [OR]=.96; 95% CI, .95–.97), education greater than high school (OR=.69; 95% CI, .56–.85), and better self-reported mental health (OR=.95; 95% CI, .94–.97) were all associated with a lower likelihood of current smoking. Being unmarried (OR=1.63; 95% CI, 1.30–2.09), higher levels of physical pain (OR=1.12; 95% CI, 1.02–1.20), and better self-reported physical health (OR=1.03; 95% CI, 1.01–1.15) were all associated with a higher likelihood of current smoking. Sex and race were unrelated to smoking. Living alone was associated with a greater likelihood of smoking at a univariate level, but failed to maintain significance in the multivariate model (table 2). Unmet Need for Smoking Cessation Service and Correlates Unmet need for smoking cessation services was reported by 59.0% (95% CI, 51.1–66.4) of current smokers. Multivariate logistic regression identified no variables uniquely associated with the need for services (see table 2). Quit Attempts and Correlates Among current smokers, a total of 54.5% (95% CI, 46.6–62.1) stated that they had attempted to quit smoking for a full day or longer during the past year. Multivariate logistic regression identified 2 variables uniquely associated with quit attempts. Higher levels of education (adjusted OR=2.66; 95% CI, 1.30–5.42) and higher levels of physical pain (OR=1.42; 95% CI, 1.06–1.89) were both associated with a higher likelihood of a quit attempt in the past year (see table 2). Discussion Results of this study provide the first estimate of smoking rates in a large national sample of persons with MS, as well as the first description of smoking correlates, quit attempts, and perceived unmet need for services. Despite widely recognized global health consequences, and emerging knowledge of MS-specific health consequences, nearly one third of veterans with MS were current smokers (28.5%). Rates of smoking were slightly lower than for other veterans in general (30.1%),33 but higher than those found in the broader U.S. population (22.7%)34 during the same time period. Similarly, 7.2% of veterans smoked 21 or more cigarettes per day, a rate slightly lower than veterans in general during the same time period (8.8%),33 but more than twice the rate found in the U.S. population (3.5%).34 Although it is interesting to highlight these comparisons, they should be viewed cautiously, as prevalence rates did not adjust for potentially important factors such as sex and age, and published population estimates sometimes fell within the 95% CI for MS estimates. Taken as a whole, results suggest that smoking is common among persons with MS, and that rates are higher than those found in U.S. population samples, but generally similar to other veterans. Consequently, smoking remains an important concern for rehabilitation professionals to address. Overall, veterans with MS were more likely to smoke if they were younger and had lower levels of education. Both of these findings are consistent with other research on veterans and the U.S. population in general and suggest early (or better still, universal and repeated) screening for tobacco use as a part of routine medical care.33, 34, 35 Lower levels of social contact, being unmarried and to a lesser extent living alone, were associated with a greater likelihood of current smoking. Similar results have been seen in other populations of smokers and underscore the fact that external social support may not always be available to persons considering smoking cessation.36, 37 The association between smoking and pain observed in this study has been frequently reported in the literature, although the nature of this relationship is likely complex. Pain has been described as a risk factor for smoking38 and smoking behavior is linked with short-term reductions in pain and distress39, 40 Smoking in turn has also been implicated in the development of new pain conditions including oral pain,41 musculoskeletal pain,38, 42 and rheumatoid arthritis.43 Regardless of causality, pain is a common experience among persons with MS,44, 45, 46 and limited evidence suggests that pain management might serve as a useful adjunct component of interventions for smoking. Veterans with MS who endorsed better mental health (lower levels of emotional distress) were also less likely to be current smokers. This finding is also consistent with the broader literature on smoking, which suggests that depression and anxiety are among the most consistent risk factors for smoking initiation,47, 48 maintenance,49, 50, 51 and relapse.49, 50, 52 The association between emotional distress and smoking is particularly salient given that 1 in 2 persons with MS will experience a major depressive episode in his/her lifetime53 and nearly a quarter may meet criteria at any given time.5 Results again suggest that addressing emotional distress remains an important component of successful smoking interventions.54 Unexpectedly, better physical functioning among veterans with MS was associated with a greater likelihood of smoking. This result stands in contrast to previous studies using the same health status instrument, and even the same 1999 LHS sample (not limited to persons with MS), which have largely found that current smoking is associated with poorer physical functioning.55, 56, 57 It is possible that physical disability and medical complications associated with the MS disease process, such as pulmonary difficulties, represent an obstacle to ongoing smoking. It is also possible that smokers with MS are more likely to fit a general profile that includes being younger, less disabled, and earlier in the disease process (although the last of these variables is not available in the current data). More than half of veterans with MS who were active smokers had made an attempt to quit in the past year, a finding that is consistent with both veterans in general33 and the larger U.S. population.58 The prevalence of failed quit attempts provides insight into the challenges of smoking cessation, but also underscores that the majority of people are actively engaged in a struggle to refrain from cigarette use and continue to be motivated to change their behavior. Finally, more than half of participants who smoked also endorsed a substantial unmet need for cessation services that was fairly uniform across demographic and health status variables. Results suggest that exposure to and availability of such services remains an important priority for patients, despite the fact that smoking might be overshadowed by the often long list of MS-related problems patients and providers discuss during a typical visit. Fortunately, access to services was fairly uniform and was not related to the demographic and health status variables examined in this study. The last several years have witnessed the proliferation and dissemination of smoking cessation services, including psychosocial support from tobacco quit lines, and the wide use of pharmacotherapy such as nicotine replacement therapies and bupropion to reduce craving. All of these interventions are well supported by the available literature for use in general populations,59 and appear promising for persons with MS. Future work is necessary to determine the extent to which the availability of these services has met the reported need, or whether obstacles to participation remain. Study Limitations Several limitations of the current study should be noted. First, study data were obtained from available information created by the linkage of 2 large national VA databases. The survey response rate was 64% and respondents tended to be older and, to a lesser degree, disproportionately nonwhite. It is also possible that persons who received surveys and those who returned them differed on demographic or disease factors not assessed in this study. Consequently, it is possible that this selective responding introduced bias into the estimates of smoking prevalence, correlates, and services. Results also may not generalize to people with MS who are not veterans and do not receive care in the VA health care system. As previously mentioned, health care services for smoking change frequently. In particular, perceptions of unmet need for smoking cessation services may not reflect significant recent increases in availability within and outside of the VA health care system. Nonetheless, findings are based on a large national sample representative of the age, sex, and race of known persons with MS in the VA health care system. Information on smoking was obtained from mailed surveys and may be subject to biases associated with self-report, although extensive review has repeatedly upheld the validity of smoking data obtained from questionnaire and interview formats.60 Conclusions Despite general and disease-specific health risks, smoking is common among veterans with MS and global prevalence rates exceed those found in the general population. More than half of current smokers with MS endorsed a serious quit attempt during the year prior to survey, but over half also reported that they did not receive needed services. 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a VA Puget Sound Health Care System, Seattle, WA b VA MS Center of Excellence West, Seattle, WA c VA Center of Excellence in Substance Abuse Treatment and Education, Seattle, WA d Department of Public Health, Boston University, Boston, MA e Department of Rehabilitation Medicine, University of Washington, Seattle, WA f Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA g Department of Epidemiology, University of Washington, Seattle, WA h VA Center for Health Quality, Outcomes, and Economic Research, Boston, MA.  Reprint requests to Aaron P. Turner, PhD, VA Puget Sound Health Care System, Rehabilitation Care Services, S-117-RCS, 1660 S Columbian Way, Seattle, WA 98108
Supported by a VA Rehabilitation Research and Development Service Career Development Award (grant no. B3319VA), the VA Center of Excellence in Substance Abuse Treatment and Education, the VA MS Center of Excellence West, and the VA Office of Quality and Performance. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. PII: S0003-9993(07)01340-8 doi:10.1016/j.apmr.2007.08.003 © 2007 American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved. | |
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