Smoking Cessation Screening and Treatment Among Veterans With Multiple Sclerosis

Cigarette smoking is a leading cause of preventable death in the United States and disproportionately affects veterans. While smoking cessation is the goal for all veterans, it is especially critical for veterans with multiple sclerosis (MS; VwMS), for whom smoking is more detrimental to health and function. Smoking is associated with more MS relapses/flares, greater disability, faster disease progression, and earlier MS-related death. This quality improvement project aims to describe current practice pathways for screening and treating smoking cessation in VwMS and explore whether these differ by sociodemographic factors.

A validated algorithm was used to identify VwMS who were current or former smokers at one VA hospital in North Carolina from fiscal year 2020 to 2022 who had been screened for smoking and could be followed for 1 year. A chart review was conducted by 2 reviewers and 25% of charts were audited for reliability. Data extraction was guided by the Consolidated Framework for Implementation Research. Within-group proportions were used to help compare receipt of care across different groups in the context of sociodemographic factors. This work was deemed quality improvement and not subject to IRB review.

Of all VwMS (n = 309), 39.5% (n = 122) were identified as current or former smokers. Of those, only 58% (n = 71) were eligible largely because many VwMS lacked a current screen, which was an identified gap in care. Among those screened, most screenings had taken place through primary care services (73%), and most were offered behavioral interventions at screening (n = 66), yet few were interested (n = 4) or received a referral to the cessation clinic (n = 2). One additional referral was given during the follow-up year. Most VwMS were also offered pharmacological interventions (n = 68), with more interest (n = 11) and cessation medication prescriptions (n = 8). Eleven additional VwMS received prescriptions throughout the follow-up year, but a third of those (36%) were required due to inpatient hospitalizations. While subgroup sample sizes were limited, potential disparities were noted. For example, women veterans and veterans from minoritized populations were less likely to be assessed for smoking status and offered cessation strategies.

This study identified relatively low rates of smoking cessation screening, interest in treatment, and treatment delivery for VwMS. Important racial and sex disparities were noted. There are several potential barriers and facilitators including Electronic Health Record referral logistics, veteran and provider awareness of the relationship between smoking and MS, stigma of behavioral interventions, fragmented care, and competing demands on clinicians. This work was done at one local VA hospital within North Carolina, the leading state in tobacco production, and is not necessarily representative of other hospital screening and treatment practices. The role of specialty providers (e.g., mental health and neurology) in smoking cessation for VwMS should be further explored and may be an important opportunity for improving screenings and tailored discussion. Future work, incorporating VHA clinician and VwMS perspectives, is needed to further characterize and address barriers/facilitators to improve smoking cessation care and health of VwMS.