Examining Disparities, Barriers, and Facilitators to Improving Smoking Cessation Treatment in Veterans with Multiple Sclerosis

Multiple Sclerosis (MS) is typically thought to affect younger white women and often important factors are underrecognized in other populations, including veterans. That is one of the reasons that Duke University School of Nursing postdoctoral fellow and clinical associate Carri Polick, Ph.D., RN, is conducting a study that examines smoking cessation among veterans with MS and how social determinants of health might affect treatment of veterans’ smoking addiction and disease trajectory.

“If a patient does not fit that typical case example that we are given throughout healthcare education, are they being underrecognized and undertreated? Does it take providers longer to recognize some of these issues?” asked Polick, whose one-year pilot study is through the Veteran’s Affairs (VA) Health Services Research and Development (HSR&D) and Mental Illness Research Education and Clinical Center (MIRECC). MS diagnoses have nearly doubled in veterans over the last two decades, and while veterans overall are just slightly more likely to smoke than the general population at 13% versus 11%, throughout North Carolina and Virginia 36% - 43% of veterans with MS smoke. Smoking raises the chances of developing MS, worsens disabilities, and quickens disease progression, Polick said, but there is not a lot of awareness among patients or all of their healthcare providers

“This really aligns with the school of nursing’s strategic planning of nurse-led models of care,” Polick said, noting that fragmented health care means things like treating smoking cessation may go unaddressed. Under a Transmural model of care, a nurse leader can serve as an intermediary between primary and specialty care to help optimize health and engagement with the health system. For example, using the Electronic Health Record (EHR) to proactively identify patients that smoke, engage with them to increase awareness of the impact on MS, and deliver cessation treatment or connect them to other resources could be a high impact model to fill gaps between health services.

MS is a neuroimmune degenerative disease that affects the central nervous system. Once function is lost from MS, it typically does not fully come back, so early intervention is key. Additionally, studies have shown that people who smoke are more likely to develop antibodies to immunologic MS treatments, rendering them less effective. Smoking is also related to earlier MS-related death. Therefore, cessation treatment can help improve current symptoms and quality of life, and also improve the disease course and longevity.

The new pilot study will focus on why this disparity of care exists and includes an examination of one year of records from the local VA and a national survey of providers through the MS Center of Excellence. The survey inquiries about providers’ assessments of how social determinants of health might affect their prescribed treatment and their patients’ response. For instance, are rural patients less likely to engage in treatment because of accessibility issues?

“We’re trying to determine the current pathways that people received treatment, and whether that differs by factors like sex, ethnicity, race, or rurality. That’s one piece,” Polick said. “We are also trying to assess what providers are perceiving as barriers and facilitators and potential disparities.” With a research background in social drivers of health, or stressors, Polick notes that traditional stressors include childhood trauma, neglect, and abuse. Polick has shown that stressors that encompass social determinants of health, such as housing instability, job insecurity and discrimination stress, can be just as significant to health outcomes. Smoking is often a response to stress that becomes an addiction, not necessarily a choice, and patients need help addressing it. The study aims to provide foundation for further work in the area of MS and smoking, Polick said. “It’s important to give people the best chance to maintain their quality of life and their longevity.”