The Quit Rates Didn't Move. The Veterans Trial Kept Something Worth Having.

Veterans who smoke are more likely to die by suicide than veterans who do not, and the evidence that quitting lowers that risk is suggestive rather than settled. What is settled is that the people at highest risk are usually kept out of the trials that would answer the question. Investigators at VA San Diego built a small study around that exclusion, and the results, published November 10 in Nicotine & Tobacco Research, are a null on quitting and a small opening somewhere else.

Sixty-eight veterans who used cigarettes, e-cigarettes or both every day were randomized to a dialectical behavior therapy cessation program or to treatment as usual. Both groups got twelve weekly group psychotherapy sessions and were followed for 24 weeks. Abstinence did not differ between arms at the end of treatment or at six months. Emotion regulation improved somewhat more in the DBT arm, a difference the authors describe as a trend.

What the null actually compares

The design detail that decides how to read this is the twelve weekly groups in both conditions. The trial did not test whether therapy helps veterans quit; it tested whether DBT content outperforms standard cessation content when everyone receives the same amount of group time. That is the more useful question, and the answer is no — not on abstinence, over six months.

It is also the question a pilot of this size cannot answer well. With 68 people split across two arms, the study has room to detect only a large difference in quit rates, and the authors present it as preliminary evidence rather than a verdict. A null here means the effect, if it exists, is smaller than this trial could see.

The participants are the part of the study that will not be replicated easily. These were daily tobacco users screened as being at elevated suicide risk — a group that cessation researchers typically exclude on safety grounds, and whose absence from the literature is why so little is known about whether quitting helps them. Sixty-eight of them enrolled voluntarily, attended weekly groups, and stayed in follow-up for six months. For a field that has argued high-risk patients cannot be engaged in cessation treatment, that is a result in itself.

Why the emotional signal matters more than the quit rate

DBT was designed for people who cope with distress by doing something immediately harmful, and its skills target the moment between an urge and an act. Smoking fits that model cleanly, which is why the researchers hypothesized that teaching distress tolerance and emotion regulation would do something that nicotine replacement cannot.

The emotion regulation trend is the only place in the data where that hypothesis shows up. It is thin — a trend in a small sample, not a corrected secondary endpoint — and it should be reported as thin. But it points at a defensible clinical posture: for a veteran in dialectical behavior therapy for other reasons, adding cessation to the same skills group costs nothing structurally and may help with the regulation problem the therapy already targets. Swapping a working cessation program for a DBT one on the strength of this trial would be reading it backwards.

What the study does establish is feasibility: the population exists, will show up, and can be followed. The authors' own conclusion asks for a larger trial. The useful question for that trial is not whether DBT beats usual care at six months, but whether quitting changes suicide-related outcomes over a year — the outcome this pilot was too small to measure.