Background

Nearly 45 million U.S. adults smoke cigarettes, causing death or disability in half of this population. Tobacco relates to more deaths than AIDS, illicit drugs, alcohol use, auto accidents, suicide and homicides combined. The annual economic impact of tobacco smoking is $96 billion in medical expenses and $97 billion in lost productivity. 

Those with mental illness are disproportionately affected, dying on average 25 years early, yet smoking rates are increasing in this population. In a U.S. study, smokers with psychiatric disorders were nearly half of the 520,000 annual tobacco-related deaths. Veterans with posttraumatic stress disorder (PTSD) are more likely to smoke, tripling the risk of tobacco use disorder. Most veterans who smoke are interested in quitting, yet those with PTSD have the lowest rates of successful cessation. 

Noninvasive brain stimulation such as repetitive transcranial magnetic stimulation (rTMS) can safely modulate cortical and subcortical functioning. By targeting neurocircuitry implicated in substance use disorders, rTMS can induce long-lasting changes in the brain that ultimately influence behavior. 

Unfortunately, there is a lack of research on rTMS for smoking cessation in populations with psychiatric illness, including veterans with PTSD. In a review of current clinical trials, none focuses on those with PTSD and most exclude comorbid psychiatric illness, which may contribute to treatment/health disparities. Further study is needed in order to support addiction recovery.

Project Description

This project aims to evaluate the feasibility and acceptability of a multimodal smoking cessation treatment that includes neuronavigated rTMS, cognitive behavioral therapy and nicotine replacement therapy. The team will evaluate the impact of these treatments and elucidate the mechanisms of the rTMS intervention, including changes in brain functional connectivity. 

Participants will be identified and recruited from the Durham Veterans Affairs Health Care System. Recent data shows that approximately one in three of the over 12,750 veterans enrolled there currently smoke.

This project will encompass two prospective longitudinal intervention studies:

• Phase 1: Completion of data analysis and publication of an ongoing pilot study. The team will use descriptive, bivariate and multivariate analyses to evaluate outcomes including recruitment, retention, acceptability and efficacy. 
• Phase 2: Preparation and initiation of a larger rTMS study. The team will streamline data collection by creating web-based surveys, and will explore machine learning-based software for neuroimaging analysis.

The long-term goal is to build a platform from which to model future treatment development for a variety of clinical populations with substance use disorders through the integration of noninvasive neuromodulation, neuroimaging and evidence-based pharmacotherapy and psychotherapy.

Anticipated Outputs

Jonathan R. Young, Jeffrey T. Galla, Carri S. Polick, Zhi-De Deng, Moritz Dannhauer, Angela Kirby, Michelle Dennis, Claire W. Papanikolas, Mariah K. Evans, Scott D. Moore, Eric A. Dedert, Merideth A. Addicott, Lawrence G. Appelbaum, Jean C. Beckham. Multimodal Smoking Cessation Treatment Combining Transcranial Magnetic Stimulation, Cognitive Behavioral Therapy, and Nicotine Replacement Therapy in Veterans With Posttraumatic Stress Disorder: A Feasibility Randomized Controlled Trial Protocol. 2023. Preprint.

Student Opportunities

Ideally, this team will include 2-3 graduate and 4-6 undergraduate students. Familiarity with statistical software (e.g., STATA, R) and/or experience or interest in learning about survey tools (e.g., Qualtrics, REDCap), traumatic stress responses, neuroimaging, brain stimulation or addiction research is preferred. Interested applicants might come from such disciplines as psychology, neuroscience, mathematics, biostatistics, computer science and biomedical engineering as well as professional health sciences. Students with related research and/or clinical training in other disciplines are also welcome.

Team members will gain understanding and skills in rTMS, MRI, cognitive behavioral therapy, STATA and survey development. Learning will occur through hands-on training, lectures and discussions.  All team members will receive the opportunity to contribute to an academic publication. Graduate students will have opportunities for leadership, honing review and feedback skills as they work with undergraduate students. Undergraduate students will be exposed to an innovative study bridging clinical, technological and academic realms to help inform their future career decisions.

Timing

Fall 2023 – Spring 2024

• Fall 2023: Complete data analyses, manuscript writing and dissemination for Phase 1; create online survey for collection of self-report data and assist with Institutional Review Board (IRB), MRI and TMS procedures for Phase 2
• Spring 2024: Implement clinical trial; administer MRI, TMS and associated procedures for Phase 2

Crediting

Academic credit available for fall and spring semesters.

Image: Exterior view of Durham VA Medical Center, by Duke School of Medicine, Radiation Oncology