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Abstract

CONTEXT:

Most smokers with mental illness do not receive tobacco cessation treatment.

OBJECTIVE:

To determine whether integrating smoking cessation treatment into mental health care for veterans with posttraumatic stress disorder (PTSD) improves long-term smoking abstinence rates.

DESIGN, SETTING, AND PATIENTS:

A randomized controlled trial of 943 smokers with military-related PTSD who were recruited from outpatient PTSD clinics at 10 Veterans Affairs medical centers and followed up for 18 to 48 months between November 2004 and July 2009.

INTERVENTION:

Smoking cessation treatment integrated within mental health care for PTSD delivered by mental health clinicians (integrated care [IC]) vs referral to Veterans Affairs smoking cessation clinics (SCC). Patients received smoking cessation treatment within 3 months of study enrollment.

MAIN OUTCOME MEASURES:

Smoking outcomes included 12-month bioverified prolonged abstinence (primary outcome) and 7- and 30-day point prevalence abstinence assessed at 3-month intervals. Amount of smoking cessation medications and counseling sessions delivered were tested as mediators of outcome. Posttraumatic stress disorder and depression were repeatedly assessed using the PTSD Checklist and Patient Health Questionnaire 9, respectively, to determine if IC participation or quitting smoking worsened psychiatric status.

RESULTS:

Integrated care was better than SCC on prolonged abstinence (8.9% vs 4.5%; adjusted odds ratio, 2.26; 95% confidence interval [CI], 1.30-3.91; P = .004). Differences between IC vs SCC were largest at 6 months for 7-day point prevalence abstinence (78/472 [16.5%] vs 34/471 [7.2%], P < .001) and remained significant at 18 months (86/472 [18.2%] vs 51/471 [10.8%], P < .001). Number of counseling sessions received and days of cessation medication used explained 39.1% of the treatment effect. Between baseline and 18 months, psychiatric status did not differ between treatment conditions. Posttraumatic stress disorder symptoms for quitters and nonquitters improved. Nonquitters worsened slightly on the Patient Health Questionnaire 9 relative to quitters (differences ranged between 0.4 and 2.1, P = .03), whose scores did not change over time.

CONCLUSION:

Among smokers with military-related PTSD, integrating smoking cessation treatment into mental health care compared with referral to specialized cessation treatment resulted in greater prolonged abstinence.

TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT00118534.

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Publication Type
Journal Articles
Publication Date
Journal Publisher
JAMA
Authors
Mark W. Smith
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Symposium Outline

Ten years after President Bush attempted to reduce U.S. involvement in statebuilding, America and its allies are more heavily involved in it than ever before.  There simply are no viable alternatives to stabilizing fragile states. And yet the tremendous sacrifices we make to rebuild states too often produce regimes where corruption and other abuses of power prevail. In turn these undermine the legitimacy of the regimes and render stability ever more elusive.

The international community may share responsibility for creating this accountability gap. In Afghanistan, the rush to build up the power of the government and to respect its sovereignty have weakened constraints that would subject that power to the will of the Afghan people.

Amid struggles over flawed elections and corruption these past two years, practitioners on the ground have experimented with new approaches to close the accountability gap in Afghanistan. NATO military approaches to governance-led operations have been matched by parallel civilian efforts to work from the bottom-up in engaging Afghan communities and helping them seek solutions through the nascent institutions of the Afghan government. 

These efforts face an uphill challenge, but represent the best hope for closing an accountability gap that threatens all statebuilding efforts. This symposium at Stanford University will bring together practitioners and experts to share experiences and explore options to improve the contemporary practice of statebuilding.

Organizers

The symposium will be hosted by Larry Diamond, Director of the Center on Democracy, Development and the Rule of Law. Founded in 2002, CDDRL engages in research, training, and teaching, organizing policy dialogues aimed at increasing public understanding of governance and political development. In addition, CDDRL collaborates with scholars, policymakers, and practitioners around the world to advance collective knowledge about the linkages between democracy, sustainable economic development, human rights, and the rule of law.

The research team supporting the symposium is led by Ben Rowswell, a Visiting Scholar who is in residence at CDDRL during the 2010-2011 academic year to carry out the project entitled, Promoting Popular Sovereignty in Statebuilding. Rowswell is a Canadian diplomat on leave, who has recently served both as Director of the Kandahar Provincial Reconstruction Team and as Deputy Head of Mission for the Canadian Embassy in Kabul.  Promoting Popular Sovereignty in Statebuilding and the associated symposium have been made possible by a generous contribution from the Global Peace and Security Fund of Canada's Department of Foreign Affairs and International Trade.

Bechtel Conference Center

CDDRL
Stanford University
Encina Hall, C147
616 Jane Stanford Way
Stanford, CA 94305-6055

(650) 724-6448 (650) 723-1928
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Mosbacher Senior Fellow in Global Democracy at the Freeman Spogli Institute for International Studies
William L. Clayton Senior Fellow at the Hoover Institution
Professor, by courtesy, of Political Science and Sociology
diamond_encina_hall.png MA, PhD

Larry Diamond is the William L. Clayton Senior Fellow at the Hoover Institution, the Mosbacher Senior Fellow in Global Democracy at the Freeman Spogli Institute for International Studies (FSI), and a Bass University Fellow in Undergraduate Education at Stanford University. He is also professor by courtesy of Political Science and Sociology at Stanford, where he lectures and teaches courses on democracy (including an online course on EdX). At the Hoover Institution, he co-leads the Project on Taiwan in the Indo-Pacific Region and participates in the Project on the U.S., China, and the World. At FSI, he is among the core faculty of the Center on Democracy, Development and the Rule of Law, which he directed for six and a half years. He leads FSI’s Israel Studies Program and is a member of the Program on Arab Reform and Development. He also co-leads the Global Digital Policy Incubator, based at FSI’s Cyber Policy Center. He served for 32 years as founding co-editor of the Journal of Democracy.

Diamond’s research focuses on global trends affecting freedom and democracy and on U.S. and international policies to defend and advance democracy. His book, Ill Winds: Saving Democracy from Russian Rage, Chinese Ambition, and American Complacency, analyzes the challenges confronting liberal democracy in the United States and around the world at this potential “hinge in history,” and offers an agenda for strengthening and defending democracy at home and abroad.  A paperback edition with a new preface was released by Penguin in April 2020. His other books include: In Search of Democracy (2016), The Spirit of Democracy (2008), Developing Democracy: Toward Consolidation (1999), Promoting Democracy in the 1990s (1995), and Class, Ethnicity, and Democracy in Nigeria (1989). He has edited or coedited more than fifty books, including China’s Influence and American Interests (2019, with Orville Schell), Silicon Triangle: The United States, China, Taiwan the Global Semiconductor Security (2023, with James O. Ellis Jr. and Orville Schell), and The Troubling State of India’s Democracy (2024, with Sumit Ganguly and Dinsha Mistree).

During 2002–03, Diamond served as a consultant to the US Agency for International Development (USAID) and was a contributing author of its report, Foreign Aid in the National Interest. He has advised and lectured to universities and think tanks around the world, and to the World Bank, the United Nations, the State Department, and other organizations dealing with governance and development. During the first three months of 2004, Diamond served as a senior adviser on governance to the Coalition Provisional Authority in Baghdad. His 2005 book, Squandered Victory: The American Occupation and the Bungled Effort to Bring Democracy to Iraq, was one of the first books to critically analyze America's postwar engagement in Iraq.

Among Diamond’s other edited books are Democracy in Decline?; Democratization and Authoritarianism in the Arab WorldWill China Democratize?; and Liberation Technology: Social Media and the Struggle for Democracy, all edited with Marc F. Plattner; and Politics and Culture in Contemporary Iran, with Abbas Milani. With Juan J. Linz and Seymour Martin Lipset, he edited the series, Democracy in Developing Countries, which helped to shape a new generation of comparative study of democratic development.

Download full-resolution headshot; photo credit: Rod Searcey.

Former Director of the Center on Democracy, Development and the Rule of Law
Faculty Chair, Jan Koum Israel Studies Program
Date Label
Larry Diamond Director CDDRL Speaker Stanford University

Encina Hall
616 Serra Street
Stanford, CA 94305

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CDDRL Visiting Scholar 2010-11
Rowswell_pic.jpg

Ben Rowswell is a Canadian diplomat with a specialization in statebuilding and stabilization. As Representative of Canada in Kandahar from 2009 to 2010 he directed the Kandahar Provincial Reconstruction Team, leading a team of more than 100 American and Canadian diplomats, aid workers, civilian police and other experts in strengthening the provincial government at the heart of the Afghan conflict. Having served before that as Deputy Head of Mission in Kabul, Rowswell brings a practitioner's knowledge of Afghanistan and of statebuilding in general to the CDDRL.

His previous conflict experience includes two years as Canada's Chargé d'Affaires in Iraq between 2003 and 2005, and with the UN in Somalia in 1993. He has also served at the Canadian embassy in Egypt and the Permanent Mission to the UN, and as a foreign policy advisor to the federal Cabinet in Ottawa. An alumnus of the National Democratic Institute, he founded the Democracy Unit of the Canadian foreign ministry.

Rowswell is a Senior Associate of the Center for Strategic and International Studies and the co-editor of "Iraq: Preventing a New Generation of Conflict" (2007). He studied international relations at Oxford and at Georgetown University's School of Foreign Service.

Ben Rowswell Visiting Scholar, CDDRL Panelist Stanford University
Ashraf Ghani Former Afghan Minister of Finance and Presidential Candidate Keynote Speaker
Ambassador Ronald Neumann US Ambassador to Afghanistan 2005-2007 Panelist

Encina Hall, C148
616 Jane Stanford Way
Stanford, CA 94305

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Olivier Nomellini Senior Fellow at the Freeman Spogli Institute for International Studies
Director of the Ford Dorsey Master's in International Policy
Research Affiliate at The Europe Center
Professor by Courtesy, Department of Political Science
yff-2021-14290_6500x4500_square.jpg

Francis Fukuyama is the Olivier Nomellini Senior Fellow at Stanford University's Freeman Spogli Institute for International Studies (FSI), and a faculty member of FSI's Center on Democracy, Development and the Rule of Law (CDDRL). He is also Director of Stanford's Ford Dorsey Master's in International Policy, and a professor (by courtesy) of Political Science.

Dr. Fukuyama has written widely on issues in development and international politics. His 1992 book, The End of History and the Last Man, has appeared in over twenty foreign editions. His book In the Realm of the Last Man: A Memoir will be published in fall 2026.

Francis Fukuyama received his B.A. from Cornell University in classics, and his Ph.D. from Harvard in Political Science. He was a member of the Political Science Department of the RAND Corporation, and of the Policy Planning Staff of the US Department of State. From 1996-2000 he was Omer L. and Nancy Hirst Professor of Public Policy at the School of Public Policy at George Mason University, and from 2001-2010 he was Bernard L. Schwartz Professor of International Political Economy at the Paul H. Nitze School of Advanced International Studies, Johns Hopkins University. He served as a member of the President’s Council on Bioethics from 2001-2004. He is editor-in-chief of American Purpose, an online journal.

Dr. Fukuyama holds honorary doctorates from Connecticut College, Doane College, Doshisha University (Japan), Kansai University (Japan), Aarhus University (Denmark), the Pardee Rand Graduate School, and Adam Mickiewicz University (Poland). He is a non-resident fellow at the Carnegie Endowment for International Peace. He is a member of the Board of Trustees of the Rand Corporation, the Board of Trustees of Freedom House, and the Board of the Volcker Alliance. He is a fellow of the National Academy for Public Administration, a member of the American Political Science Association, and of the Council on Foreign Relations. He is married to Laura Holmgren and has three children.

(October 2025)

CV
Date Label
Francis Fukuyama Olivier Nominelli Fellow, CDDRL Moderator Stanford University
Ambassador Said Jawad Afghan Ambassador to US 2003-2010 Panelist
Erik Jensen Co-Director Rule of Law Program Moderator Stanford Law School
Shuvaloy Majumdar Former Country Director for Afghanistan, International Republican Institute Panelist
Tom Fingar Oksenberg/Rohlen Distinguished Fellow Moderator Freeman Spogli Institute, Stanford
Stephen Stedman Senior Fellow, FSI Speaker Stanford University
Roland Paris Director Panelist Centre for International Policy Studies, University of Ottawa
Major General Nick Carter Commander, ISAF Regional Command South (2009-10) Panelist UK Ministry of Defence
Joanne Trotter Panelist Aga Khan Development Network
Elissa Golberg Director-General, Stabilization and Reconstruction Task Force Moderator Canadian Department of Foreign Affairs and International Trade
Grant Kippen Former Chair Panelist Electoral Complaints Commission of Afghanistan
Gerard Russell Former UNAMA Political Officer Panelist
Michael Semple Carr Center for Human Rights Panelist Harvard University
Tarek Ghani Panelist University of California, Berkeley
Ambassador Jawad Ludin Former Afghan Ambassador to Canada, 2009-10 Panelist
Andrew Wilder Panelist US Institute for Peace
Minna Jarvenpaa Former Political Officer Panelist UNAMA
Farhaan Ladhani Director of Strategic Communications Panelist Kandahar Provincal Reconstruction Team, 2009-2010
James Traube Contributing Writer Speaker New York Times Magazine
Symposiums
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China and the World: The Stanford China Program, in cooperation with the Center for East Asian Studies, will host a special series of seminars to examine China as a major political and economic actor on the world stage. Over the course of the autumn and winter terms, leading scholars will examine China's actions and policies in the new global political economy. What is China's role in global governance? What is the state of China's relations with its Asian neighbors? Is China being more assertive both diplomatically as well as militarily? Are economic interests shaping its foreign policies? What role does China play amidst international conflicts?

M. Taylor Fravel is the Cecil and Ida Green Career Development Associate Professor of Political Science and member of the Security Studies Program at MIT. He studies international relations, with a focus on international security, China, and East Asia.  His current projects examine the evolution of China's military strategy since 1949 and the relationship between material capabilities and political influence in China's rise as a great power.

This event is part of the China and the World series.

Philippines Conference Room

M. Taylor Fravel Associate Professor of Political Science Speaker MIT
Seminars
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Oak Lounge

Brian Turner Award-winning poet and author of Here, Bullet Speaker
Jason R. Armagost Visiting scholar at CISAC and a Lieutenant Colonel in the U.S. Air Force Speaker
Richard Rhodes Pulitzer Prize winning author and affiliate, CISAC Moderator
Seminars
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