Patterns of tobacco-related mortality among individuals diagnosed with schizophrenia, bipolar disorder, or depression

Protocol for an Economic Evaluation of the Quitlink Randomized Controlled Trial for Accessible Smoking Cessation Support for People With Severe Mental Illness

Introduction: Smoking is a major cause of disease burden and reduced quality of life for people with severe mental illness (SMI). It places significant resource pressure on health systems and financial stress on smokers with SMI (SSMI). Telephone-based smoking cessation interventions have been shown to be cost effective in general populations. However, evidence suggests that SSMI are less likely to be referred to quitlines, and little is known about the effectiveness and cost effectiveness of such interventions that specifically target SSMI. The Quitlink randomized controlled trial for accessible smoking cessation support for SSMI aims to bridge this gap. This paper describes the protocol for evaluating the cost effectiveness of Quitlink. Methods: Quitlink will be implemented in the Australian setting, utilizing the existing mental health peer workforce to link SSMI to a tailored quitline service. The effectiveness of Quitlink will be evaluated in a clustered randomized controlled trial. A cost-effectiveness evaluation will be conducted alongside the Quitlink clustered randomized controlled trial (RCT) with incremental cost-effectiveness ratios (ICERs) calculated for the cost (AUD) per successful quit and quality adjusted life year (QALY) gained at 8 months compared with usual care from both health care system and limited societal perspectives. Financial implications for study participants will also be investigated. A modeled cost-effectiveness analysis will also be conducted to estimate future costs and benefits associated with any treatment effect observed during the trial. Results will be extrapolated to estimate the cost effectiveness of rolling out Quitlink nationally. Sensitivity analyses will be undertaken to assess the impact on results from plausible variations in all modeled variables. Discussion: SSMI require additional support to quit. Quitlink utilizes existing peer worker and quitline workforces and tailors quitline support specifically to provide that increased cessation support. Given Quitlink engages these existing skilled workforces, it is hypothesized that, if found to be effective, it will also be found to be both cost effective and scalable. This protocol describes the economic evaluation of Quitlink that will assess these hypotheses. Ethics and dissemination: Full ethics clearances have been received for the methods described below from the University of Newcastle (Australia) Human Research Ethics Committee (H-2018-0192) and St Vincent's Hospital, Melbourne (HREC/18/SVHM/154). The trial has been registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12619000244101). Participant consent is sought both to participate in the study and to have the study data linked to routine health administrative data on publicly subsidized health service and pharmaceutical use, specifically the Medicare Benefits and Pharmaceutical Benefits Schemes (MBS/PBS). Trial findings (including economic evaluation) will be published in peer reviewed journals and presented at international conferences. Collected data and analyses will be made available in accordance with journal policies and study ethics approvals. Results will be presented to relevant government authorities with an interest in cost effectiveness of these types of interventions.

"Quitlink"-A Randomized Controlled Trial of Peer Worker Facilitated Quitline Support for Smokers Receiving Mental Health Services: Study Protocol

Introduction: Although smokers with severe mental illnesses (SSMI) make quit attempts at comparable levels to other smokers, fewer are successful in achieving smoking cessation. Specialized smoking cessation treatments targeting their needs can be effective but have not been widely disseminated. Telephone delivered interventions, including by quitlines, show promise. However, few SSMI contact quitlines and few are referred to them by health professionals. Mental health peer workers can potentially play an important role in supporting smoking cessation. This study will apply a pragmatic model using peer workers to engage SSMI with a customized quitline service, forming the "Quitlink" intervention. Methods: A multi-center prospective, cluster-randomized, open, blinded endpoint (PROBE) trial. Over 3 years, 382 smokers will be recruited from mental health services in Victoria, Australia. Following completion of baseline assessment, a brief intervention will be delivered by a peer worker. Participants will then be randomly allocated either to no further intervention, or to be referred and contacted by the Victorian Quitline and offered a targeted 8-week cognitive behavioral intervention along with nicotine replacement therapy (NRT). Follow-up measures will be administered at 2-, 5-, and 8-months post-baseline. The primary outcome is 6 months continuous abstinence from end of treatment with biochemical verification. Secondary outcomes include 7-day point prevalence abstinence from smoking, increased quit attempts, and reductions in cigarettes per day, cravings and withdrawal, mental health symptoms, and other substance use, and improvements in quality of life. We will use a generalized linear mixed model (linear regression for continuous outcomes and logistic regression for dichotomous outcomes) to handle clustering and the repeated measures at baseline, 2-, 5-, and 8-months; individuals will be modeled as random effects, cluster as a random effect, and group assignment as a fixed effect. Discussion: This is the first rigorously designed RCT to evaluate a specialized quitline intervention accompanied by NRT among SSMI. The study will apply a pragmatic model to link SSMI to the Quitline, using peer workers, with the potential for wide dissemination. Clinical Trial Registration: Trial Registry: The trial is registered with ANZCTR (www.anzctr.org.au): ACTRN12619000244101 prior to the accrual of the first participant and updated regularly as per registry guidelines. Trial Sponsor: University of Newcastle, NSW, Australia.

Psychosocial Factors Affecting Smoking Cessation Among People Living With Schizophrenia: A Lived Experience Lens

Introduction: People living with schizophrenia smoke at much higher rates than the general population, and find it more difficult to quit. To date, lived experience has received little attention from researchers. Personal recovery perspectives may generate further insights into established psychosocial barriers and enablers of smoking cessation. Methods and Results: A lived experience account is provided by one of our authors that places the current evidence in context, and highlights the role of marginalization and stigma in reinforcing smoking. Key concepts from the personal recovery paradigm, such as connectedness, hope, and empowerment are discussed. The relevance of these factors and the value of shared lived experience in challenging stigma, marginalization, and low expectations demonstrates the contribution that peer support can offer to support smoking cessation. Conclusions: Recovery-oriented approaches when integrated with existing evidence-based treatments designed to meet the needs of people living with schizophrenia have potential to improve outcomes by helping to take a more holistic approach to break down barriers and facilitate increased uptake of treatment and support. Further research to evaluate the effectiveness of integrated approaches is warranted.

Neurobiological Determinants of Tobacco Smoking in Schizophrenia

Purpose of review: To provide an overview of the underlying neurobiology of tobacco smoking in schizophrenia, and implications for treatment of this comorbidity. Recent findings: Explanations for heavy tobacco smoking in schizophrenia include pro-cognitive effects of nicotine, and remediation of the underlying pathophysiology of schizophrenia. Nicotine may ameliorate neurochemical deficits through nicotine acetylcholine receptors (nAChRs) located on the dopamine, glutamate, and GABA neurons. Neurophysiological indices including electroencephalography, electromyography, and smooth pursuit eye movement (SPEM) paradigms may be biomarkers for underlying neuronal imbalances that contribute to the specific risk of tobacco smoking initiation, maintenance, and difficulty quitting within schizophrenia. Moreover, several social factors including socioeconomic factors and permissive smoking culture in mental health facilities, may contribute to the smoking behaviors (initiation, maintenance, and inability to quit smoking) within this disorder. Summary: Tobacco smoking may alleviate specific symptoms associated with schizophrenia. Understanding the neurobiological underpinnings and psychosocial determinants of this comorbidity may better explain these potential beneficial effects, while also providing important insights into effective treatments for smoking cessation.

Cigarette smoking among those with mental disorders in the US population: 2012-2013 update

BACKGROUND

Recent nationally representative estimates from the USA suggest the prevalence of cigarette smoking continues to be much higher among those with mental disorders compared with those without; however, prevalence estimates for current cigarette use by specific diagnoses are outdated.

METHODS

We analysed data from the National Epidemiologic Survey on Alcohol and Related Conditions III (2012-2013). We estimated the prevalence of lifetime and past-year smoking, lifetime and past-year daily smoking, and lifetime smoking cessation among ever smokers (ie, the quit ratio) among those with common mood, anxiety and substance use disorders in comparison to those without these disorders.

RESULTS

Across disorders, smoking prevalence was higher and the quit ratio was lower among those with common mental disorders compared with those without, with twofold to sixfold relativedifferences in the odds of the magnitude.

CONCLUSIONS

Despite tobacco control advances since 2000 and resulting declines in smoking prevalence, smoking remains extraordinarily more common among those with mood, anxiety and substance use disorders, with highest rates among those with bipolar and substance use disorders.

Tobacco Use and Associated Factors in Patients Presenting to a Psychiatric Emergency Room

Background

Rates of cigarette smoking among the public and individuals with mental illness have been well documented. Studies have demonstrated that prevalence of smoking among individuals with mental illness remains elevated compared to the general population and as a distinct subgroup, individuals with mental illness consume more than a third of cigarettes sold in the U.S. However, information on rates of smoking among patients presenting to a psychiatric emergency room (ER) is lacking. This study assesses this understudied population for smoking prevalence and associated factors.

Methods

A retrospective chart review of 203 distinct psychiatric ER patients was conducted. Demographics, tobacco use, substance use, psychiatric diagnoses, and family history were noted and analyzed with SPSS.

Result

Tobacco use rates were noted to be nearly fifty percent and significant associations were found with active suicidal ideation, alcohol use disorders, illicit drug use disorders, and history of prior psychiatric hospitalization.

Conclusion

Tobacco use among psychiatric ER patients is much higher than that of the general population and associated with active suicidal ideations, alcohol use disorders, and illicit substance use disorders. These findings should be considered in the evaluation and expectant management of these patients by their clinicians and healthcare providers.

Existing and emerging smoking cessation options for people with schizophrenia spectrum disorders

Tobacco cigarette addiction is a deeply entrenched behavior among people with Schizophrenia Spectrum Disorders, and consequently these individuals die an average of 25 years earlier than the general population. The aim of this review was to evaluate the state-of-the-science focused on cessation and reduction interventions for people with SSD. We searched peer-reviewed articles from medline, psycinfo, web of science, scopus, and cochrane library, about cessation interventions for people with SSD. The search was carried out by combining an exhaustive list of terms denoting schizophrenic disorder and smoking cessation treatment. The review search period was limited from January 2000-November 2018, 260 studies were identified and a total of 24 of studies were included in the final review. This review demonstrates the vulnerability of smokers with SSD and underscores the need for research in these areas with large enough sample sizes to detect treatment effects: 1) outcomes using and comparing standard treatments 2) long-term cessation/reduction outcomes 3) flexible treatment options 4) more research to develop the evidence-base for e-cigarettes intervention.

Do mental health consumers want to improve their long-term disease risk behaviours? A survey of over 2000 psychiatric inpatients

Policies and clinical guidelines acknowledge the role mental health services have in addressing the physical health of individuals with a mental illness; however, little research has explored interest in reducing health risk behaviours or the acceptability of receiving support to reduce such risks among psychiatric inpatients. This study estimated the prevalence of four long-term disease risk behaviours (tobacco smoking, hazardous alcohol consumption, inadequate fruit and/or vegetable consumption, and inadequate physical activity); patient interest in reducing these risks; and acceptability of being provided care to do so during a psychiatric inpatient stay. A cross-sectional survey was undertaken with 2075 inpatients from four inpatient psychiatric facilities in one health district in Australia (October 2012-April 2014). Prevalence of risk behaviours ranged from 50.2% (inadequate physical activity) to 94.8% (inadequate fruit and/or vegetable consumption). The majority of respondents (88.4%) had more than one risk behaviour, and most were seriously considering improving their risk behaviours (47.6% to 65.3%). The majority (80.4%) agreed that it would be acceptable to be provided support and advice to change such behaviours during their psychiatric inpatient stay. Some diagnoses were associated with smoking and hazardous alcohol consumption, interest in reducing alcohol consumption and increasing fruit and/or vegetable consumption, and acceptability of receiving advice and support. The findings reinforce the need and opportunity for psychiatric inpatient facilities to address the long-term disease risk behaviours of their patients.

Motives and perceptions regarding electronic nicotine delivery systems (ENDS) use among adults with mental health conditions

BACKGROUND

Smoking rates are disproportionately high among adults with mental health conditions (MHC), and recent research suggests that among former smokers, those with MHC are more likely to use electronic nicotine delivery systems (ENDS). This study investigated reasons for ENDS use and related risk perceptions among individuals with versus without MHC.

METHODS

Among adult current ENDS users (n=550), associations between self-reported MHC diagnoses and motives for ENDS use and ENDS risk perceptions were examined, stratified by smoking status.

RESULTS

There were no significant associations between MHC status and ENDS motives or perceptions in the overall sample. However, current smokers with MHC indicated thinking more about how ENDS might improve their health, and former smokers with MHC reported thinking less about how ENDS might harm their health, compared to their counterparts without MHC. Former smokers with MHC rated several reasons for ENDS use (e.g., less harmful than regular cigarettes; to quit smoking; appealing flavors) as more important than did those without MHC.

CONCLUSIONS

Current and former smokers with MHC may be especially optimistic about health benefits of ENDS. However, they might also be prone to health risks of continued ENDS use or concurrent use with traditional cigarettes. It will be important for public health messaging to provide this population with accurate information about benefits and risks of ENDS.

Supporting change in chronic disease risk behaviours for people with a mental illness: a qualitative study of the experiences of family carers

Background

People with a mental illness experience greater chronic disease morbidity and mortality, and associated reduced life expectancy, compared to those without such an illness. A higher prevalence of chronic disease risk behaviours (inadequate nutrition, inadequate physical activity, tobacco smoking, and harmful alcohol consumption) is experienced by this population. Family carers have the potential to support change in such behaviours among those they care for with a mental illness. This study aimed to explore family carers’: 1) experiences in addressing the chronic disease risk behaviours of their family members; 2) existing barriers to addressing such behaviours; and 3) perceptions of potential strategies to assist them to provide risk behaviour change support.

Methods

A qualitative study of four focus groups (n = 31), using a semi-structured interview schedule, was conducted with carers of people with a mental illness in New South Wales, Australia from January 2015 to February 2016. An inductive thematic analysis was employed to explore the experience of carers in addressing the chronic disease risk behaviours.

Results

Two main themes were identified in family carers’ report of their experiences: firstly, that health behaviours were salient concerns for carers and that they were engaged in providing support, and secondly that they perceived a bidirectional relationship between health behaviours and mental well-being. Key barriers to addressing behaviours were: a need to attend to carers’ own well-being; defensiveness on behalf of the family member; and not residing with their family member; with other behaviour-specific barriers also identified. Discussion around strategies which would assist carers in providing support for health risk behaviours identified a need for improved communication and collaboration between carers and health services accessed by their family members.

Conclusions

Additional support from general and mental health services accessed by family members is desired to assist carers to address the barriers to providing behaviour change support. Carers have the potential to support and extend health service interventions aimed at improving the chronic disease risk behaviours of people with a mental illness but may require additional information, and collaboration from services. Further research is needed to explore these constructs in a large representative sample.

Randomised controlled trial of a healthy lifestyle intervention among smokers with psychotic disorders: Outcomes to 36 months

OBJECTIVE

People living with psychotic disorders (schizophrenia spectrum and bipolar disorders) have high rates of cardiovascular disease risk behaviours, including smoking, physical inactivity and poor diet. We report cardiovascular disease risk, smoking cessation and other risk behaviour outcomes over 36 months following recruitment into a two-arm randomised controlled trial among smokers with psychotic disorders.

METHODS

Participants ( N = 235) drawn from three sites were randomised to receive nicotine replacement therapy plus (1) a Healthy Lifestyles intervention delivered over approximately 9 months or (2) a largely telephone-delivered intervention (designed to control for nicotine replacement therapy provision, session frequency and other monitoring). The primary outcome variables were 10-year cardiovascular disease risk and smoking status, while the secondary outcomes included weekly physical activity, unhealthy eating, waist circumference, psychiatric symptomatology, depression and global functioning.

RESULTS

Significant reductions in cardiovascular disease risk and smoking were detected across the 36-month follow-up period in both intervention conditions, with no significant differences between conditions. One-quarter (25.5%) of participants reported reducing cigarettes per day by 50% or more at multiple post-treatment assessments; however, few (8.9%) managed to sustain this across the majority of time points. Changes in other health behaviours or lifestyle factors were modest; however, significant improvements in depression and global functioning were detected over time in both conditions. Participants experiencing worse 'social discomfort' at baseline (e.g. anxiety, mania, poor self-esteem and social disability) had on average significantly worse global functioning, lower scores on the 12-Item Short Form Health Survey physical scale and significantly greater waist circumference.

CONCLUSION

Although the telephone-delivered intervention was designed as a comparison condition, it achieved excellent retention and comparable outcomes. Telephone-delivered smoking cessation support may potentially help to reduce smoking rates among people with psychotic disorders. Discomfort in social situations may also be a useful target for future health interventions, addressing confidence and social skills, and promoting social networks that reduce inactivity.

An audit of the management of nicotine withdrawal in an Australian inpatient unit: are we there yet?

OBJECTIVES

This paper reports outcomes of a clinical audit of smoke-free policy implementation within an Australian inpatient psychiatric setting. It aimed to evaluate assessment of smoking status and subsequent management of nicotine withdrawal, and investigate any patient factors influencing these processes.

METHODS

A total of 67 medical case notes were retrospectively analysed for inpatients admitted to psychiatric units of a general hospital in South Australia, from July to September 2015. Patient demographic variables and information from the hospital's Smoking Assessment and Management Form (SAMF) were recorded. Data analysis involved descriptive statistics and Chi-square tests of association between dependent variables (how the SAMF was completed) and independent variables (sex, voluntary status, diagnosis).

RESULTS

The SAMF was implemented for most patients (76.1%), with 64.71% completed within 24 hours of admission; though, many were incomplete. Nicotine dependence was not properly assessed for 42.3% of smokers; 69.23% were prescribed nicotine replacement therapy (NRT), despite most scoring moderate to high nicotine dependence. No statistically significant relationships were found between patient factors and form completion.

CONCLUSIONS

SAMF completion was timely for most patients; however, sections important for determining support actions remained largely incomplete, suggesting patients' nicotine withdrawal is not being adequately addressed. More work is needed to improve inpatient staff's assessment to ensure optimal care.

Offer and Use of Smoking-Cessation Support by Depression/Anxiety Status: A Cross-Sectional Survey

Introduction: Higher levels of anxiety and depression have been found to be associated with greater difficulty in stopping smoking. This raises the question as to whether mood disturbance may be associated with exposure to, and use of, quitting support.

Aims: This study examined whether General Practitioner (GP) advice and/or offer of support, or stop-smoking service use differed between smokers reporting or not reporting depression/anxiety.

Methods: Data came from the Smoking Toolkit Study. Participants were 1,162 English adults who reported currently smoking or having stopped within the past 12 months, aged 40+ years, surveyed between April and September 2012. Anxiety/depression was assessed by the mood disturbance item of the EuroQol five dimensions questionnaire (EQ-5D). This was compared to recall of GP quit advice and/or support, and stop-smoking aid use adjusting for age, gender, and social grade.

Results/Findings: Smokers reporting depression/anxiety were more likely to recall being offered advice and support to stop smoking by their GP (OR = 1.50, 95% C.I. = 1.05–2.13). However, there were no significant differences in use of stop-smoking aids during the past year.

Conclusions: Smokers reporting depression/anxiety are more likely to be offered stop-smoking support by their GPs, but this does not appear to translate into stop-smoking aid use, despite high motivation to quit. Given higher nicotine dependence in this group, mental health specific support may need to be offered, and more needs to be done to make this offer of aid attractive.

Implementation of a Quit Smoking Programme in Community Adult Mental Health Services-A Qualitative Study

Little is known about the experiences of people with severe mental health difficulties in smoking cessation interventions. This study aimed to review the implementation of a smoking cessation programme across 16 community mental health day services. The aim was to establish the experience from both service user and facilitator perspectives and refine implementation for future groups. In-depth interviews were conducted with 20 service users and four focus groups held with 17 facilitators. Thematic analysis was used to analyse the data for emergent themes in relation to key enablers and barriers to implementation. Data from service users and facilitators revealed that implementation was enabled by an open and engaged recruitment approach; the resourcefulness of facilitators; programme materials and group-based format; combining the cessation programme with other and broader health initiatives; and participants' motivations, including health and money. Barriers included the structure of the service; the lack of a joined-up approach across the health services; literacy issues and the serial/logical process assumed by the programme. Barriers perceived as more specific to those with mental health difficulties included the use of smoking as a coping mechanism, lack of alternative activities/structure and lack of consistent determination. The tobacco free policy, implemented shortly before the programme, interestingly emerged as both a barrier and an enabler. In conclusion, although this group-based cessation programme in community mental health settings was well-received overall, a number of key barriers persist. A joined-up approach which addresses the culture of smoking in mental health settings, inconsistencies in smoking policies, and provides consistent cessation support, is needed. Care needs to be taken with the timing as overall it may not be helpful to introduce a new smoking cessation programme at the same time as a tobacco free policy.

The Convention on the Rights of Persons with Disabilities as a tobacco control tool in the mental health setting

BACKGROUND

Smoking rates remain high among people with mental health conditions, even though smoking contributes to negative mental health outcomes and is a leading cause of mortality. Many mental health facilities are not covered by smoke-free laws or do not encourage smoking cessation, and people with mental health conditions are often targeted in tobacco industry promotions.

OBJECTIVE

To analyse how the Convention on the Rights of Persons with Disabilities (CRPD), to which most countries are a Party, obliges State Parties to review policies and practices for tobacco control in the mental health setting.

METHOD

Analysis of CRPD Articles relevant to smoking and mental health.

RESULTS

The CRPD contains several provisions that oblige State Parties to address the issue of smoking and mental health, particularly in relation to quit services, smoke-free policies in mental health facilities, health education focused on correcting misperceptions about smoking and mental health, and protecting people with mental health conditions from tobacco industry targeting.

CONCLUSIONS

The CRPD is a potentially powerful tool to promote tobacco control in the mental health context.

The Diagnosis and Management of Bipolar I and II Disorders: Clinical Practice Update

Bipolar disorders, including bipolar I disorder (BP-I) and bipolar II disorder (BP-II), are common, potentially disabling, and, in some cases, life-threatening conditions. Bipolar disorders are characterized by alternating episodes of mania or hypomania and depression, or mixtures of manic and depressive features. Bipolar disorders present many diagnostic and therapeutic challenges for busy clinicians. Adequate management of bipolar disorders requires pharmacotherapy and psychosocial interventions targeted to the specific phases of illness. Effective treatments are available for each illness phase, but mood episode relapses and incomplete responses to treatment are common, especially for the depressive phase. Mood symptoms, psychosocial functioning, and suicide risk must, therefore, be continually reevaluated, and, when necessary, the plan of care must be adjusted during long-term treatment. Many patients will require additional treatment of comorbid psychiatric and substance use disorders and management of a variety of commonly co-occurring chronic general medical conditions.

Disparities in US Healthcare Provider Screening and Advice for Cessation Across Chronic Medical Conditions and Tobacco Products

BACKGROUND

Disparities in tobacco use are worsening in the United States, disproportionately affecting those with chronic medical conditions. One possible contributor is that physicians may not screen and advise cessation uniformly across patients and/or tobacco products.

OBJECTIVE

This study examined provider communications regarding cigarette and non-cigarette tobacco products among adults with chronic conditions.

DESIGN

Cross-sectional study drawn from two waves (2013-2014) of the National Survey on Drug Use and Health (NSDUH).

PARTICIPANTS

Adults (≥ 18 years) who used tobacco in the past year.

MAIN MEASURES

Prevalence of tobacco use included past-year use of cigarettes, cigars, or smokeless tobacco among those with and without chronic conditions. Chronic conditions included asthma, anxiety, coronary heart disease, depression, diabetes, hepatitis, HIV, hypertension, lung cancer, stroke, and substance abuse. Odds ratio of receipt of screening and advice to quit across chronic condition and tobacco product type were reported. Data were analyzed using logistic regression, controlling for basic sociodemographic factors and number of provider visits.

KEY RESULTS

Adults with anxiety, depression, and substance use disorders had the highest prevalence of past-year cigarette (37.2-58.2%), cigar (9.1-28.0%), and smokeless tobacco (3.1-11.7%) use. Patients with any chronic condition were more likely to receive advice to quit than those without a condition (OR 1.21-2.37, p < 0.01), although the odds were lowest among adults with mental health and substance use disorders (OR 1.21-1.35, p < 0.01). Cigarette smokers were more likely to report being screened and advised to quit than non-cigarette tobacco users (OR 1.54-5.71, p < 0.01).

CONCLUSIONS

Results support the need for provider training to expand screening and cessation interventions to include the growing spectrum of tobacco products. Screening and referral to interventions are especially needed for those with mental health and substance use disorders to reduce the disparate burden of tobacco-related disease and death.

Shared metabolic and immune-inflammatory, oxidative and nitrosative stress pathways in the metabolic syndrome and mood disorders

This review examines the shared immune-inflammatory, oxidative and nitrosative stress (IO&NS) and metabolic pathways underpinning metabolic syndrome (MetS), bipolar disorder (BD) and major depressive disorder (MDD). Shared pathways in both MetS and mood disorders are low grade inflammation, including increased levels of pro-inflammatory cytokines and acute phase proteins, increased lipid peroxidation with formation of malondialdehyde and oxidized low density lipoprotein cholesterol (LDL-c), hypernitrosylation, lowered levels of antioxidants, most importantly zinc and paraoxonase (PON1), increased bacterial translocation (leaky gut), increased atherogenic index of plasma and Castelli risk indices; and reduced levels of high-density lipoprotein (HDL-c) cholesterol. Insulin resistance is probably not a major factor associated with mood disorders. Given the high levels of IO&NS and metabolic dysregulation in BD and MDD and the high comorbidity with the atherogenic components of the MetS, mood disorders should be viewed as systemic neuro-IO&NS-metabolic disorders. The IO&NS-metabolic biomarkers may have prognostic value and may contribute to the development of novel treatments targeting neuro-immune, neuro-oxidative and neuro-nitrosative pathways.

Exploring smoking, mental health and smoking-related disease in a nationally representative sample of older adults in Ireland - A retrospective secondary analysis

OBJECTIVE

Smoking is the leading preventable cause of death among individuals with mental health difficulties (MHD). The aim of the current study was to determine the impact of smoking on the physical health of older adults with MHD in Ireland and to explore the extent to which smoking mediated or moderated associations between MHD and smoking-related diseases.

METHODS

Cross-sectional analysis of a nationally representative sample of 8175 community-dwelling adults aged 50 and over from The Irish Longitudinal Study on Ageing (TILDA) was undertaken. Multivariate adjusted logistic regression models were used to assess the association between MHD, smoking (current/past/never) and smoking-related diseases (respiratory disease, cardiovascular disease, smoking-related cancers). A number of variables were employed to identify individuals with MHD, including prescribed medication, self-reported diagnoses and self-report scales.

RESULTS

MHD was associated with current (RRRs ranging from 1.84 [1.50 to 2.26] to 4.31 [2.47 to 7.53]) and former (RRRs ranging from 1.26 [1.05 to 1.52] to 1.99 [1.19 to 3.33]) smoking and also associated with the presence of smoking-related disease (ORs ranging from 1.24 [1.01 to 1.51] to 1.62 [1.00 to 2.62]). Smoking did not mediate and rarely moderated associations between MHD and smoking-related disease.

CONCLUSIONS

Older adults in Ireland with MHD are more likely to smoke than those without such difficulties. They also experience higher rates of smoking-related disease, although smoking had no mediating and no consistent moderating role in these analyses. Findings underscore the need for attention to the physical health of those with MHD including support in smoking cessation.

Family carers: A role in addressing chronic disease risk behaviours for people with a mental illness?

People with a mental illness experience greater chronic disease morbidity and mortality compared to those without mental illness. Family carers have the potential to promote the health behaviours of those they care for however factors which may influence the extent to which they do so have not been reported. An exploratory study was conducted to investigate carers': 1) promotion of fruit and vegetable consumption, physical activity, quitting smoking, and reducing alcohol consumption; 2) perceptions of their role and ability to promote such behaviours; 3) and the association between carer perceptions and the promotion of such behaviours. A cross-sectional survey was conducted with mental health carers (N = 144, 37.6% response rate) in New South Wales, Australia in 2013. Associations between current promotion of health behaviours and carer perceptions were explored through multivariate regression analysis in 2016. A majority of respondents promoted fruit and vegetable consumption (63.8%), physical activity (60.3%), quitting smoking (56.3%), and reducing alcohol consumption (56.2%) to the person they cared for. A perception that it was ‘very important’ to have a positive influence on these behaviours was positively related with promotion of each of the four behaviours, with those holding such a view being more likely to promote such behaviours, than those who did not (odds ratio: 9.47–24.13, p < 0.001). The majority (56.2%–63.8%) of carers reported promoting the health behaviours of those they cared for, demonstrating a need and opportunity to build the capacity of carers to contribute to reducing the health risk behaviours among people with a mental illness.

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A majority of carers reported current promotion of all four health risk behaviours.

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Carer capacity to influence behaviours may be limited by several factors.

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Carer capacity may also be limited differentially for different behaviours.

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Carers were more likely to promote health behaviours if they perceived it important.

Depression and Smoking Cessation: Evidence from a Smoking Cessation Clinic with 1-Year Follow-Up

BACKGROUND

Smoking is more prevalent among people with depression. Depression may make cessation more difficult and cessation may affect depression symptoms.

PURPOSE

The aims of this study were to assess the associations between (1) baseline depression and 1-year smoking abstinence and (2) abstinence and change in depression.

METHODS

Observational study using data collected routinely in a smoking cessation clinic in the Czech Republic from 2008 to 2014. Aim 1: N = 3775 patients; 14.3% reported mild and 15.4% moderate/severe baseline depression levels measured using Beck's Depression Inventory (BDI-II). Logistic regressions assessed if depression level predicted 1-year biochemically verified abstinence while adjusting for patient and treatment characteristics. Aim 2: N = 835 patients abstinent at 1 year; change in depression was analysed using Chi-square statistics, t test and mixed method analyses of variance.

RESULTS

Rate of abstinence was lower for patients with mild (32.5%, OR = 0.68; 95% CI: 0.54 to 0.87, p = 0.002) and moderate/severe depression (25.8%; OR = 0.57, 95% CI: 0.45 to 0.74, p < 0.001) compared with patients without depression (40.5%). Across abstinent patients, the majority with baseline depression reported lower depression levels at follow-up. Overall mean (SD) BDI-II scores improved from 9.2 (8.6) to 5.3 (6.1); t(834) = 14.6, p < 0.001. There were significant main effects of time (F(1832) = 880.8, p < 0.001, partial η2 = 0.51) and baseline depression level (F(2832) = 666.4, p < 0.001, partial η2 = 0.62) on follow-up depression and a significant depression * time interaction (F(2832) = 296.5, p < 0.001, partial η2 = 0.42).

CONCLUSIONS

In this effective smoking cessation clinic, depression at the start of treatment predicted reduced smoking abstinence 1 year later. Patients abstinent from smoking experienced considerable improvement in depression.

Achieving Smoking Cessation in Individuals with Schizophrenia: Special Considerations

Premature mortality due to cardiovascular disease in those with schizophrenia is the largest lifespan disparity in the US and is growing; adults in the US with schizophrenia die, on average, 28 years earlier than those in the general population. The rate of smoking prevalence among individuals with schizophrenia is estimated to be from 64 to 79%. Smokers with schizophrenia have historically been excluded from most large nicotine-dependence treatment studies. However, converging evidence indicates that a majority of smokers with schizophrenia want to quit smoking, and that available pharmacotherapeutic smoking cessation aids are well tolerated by this population of smokers and are effective when combined with behavioral treatment. The aim of this review is to present updated evidence for safety and efficacy of smoking cessation interventions for those with schizophrenia spectrum illness. We also highlight implications of the very low abstinence rates for smokers with schizophrenia who receive placebo plus behavioral treatment in randomized trials, and review treatment approaches to address the high rate of rapid relapse observed upon pharmacologic treatment discontinuation in this population. Recommendations for monitoring for treatment-emergent nicotine withdrawal symptoms, side effects, and effects of cessation on antipsychotic medication are also provided. Smokers with schizophrenia spectrum disorders should be encouraged to quit smoking and should receive varenicline, bupropion with or without nicotine replacement therapy (NRT), or NRT, all in combination with behavioral treatment for at least 12 weeks. Maintenance pharmacotherapy may reduce relapse and improve sustained abstinence rates. Controlled trials in smokers with schizophrenia consistently show no greater rate of neuropsychiatric adverse events with pharmacotherapeutic cessation aids than with placebo.

Resistin as an inflammatory marker in patients with schizophrenia treated with clozapine

BACKGROUND

Schizophrenia is associated with excess cardiovascular comorbidity and mortality related to lifestyle factors, such as lack of physical activity, poor diet, and smoking. The prevalence of metabolic syndrome is increased among patients with schizophrenia, with the highest rates among patients on clozapine treatment. Smoking, obesity, physical inactivity, airway inflammation and obstruction, and adipose tissue and inflammatory marker activation are related in systemic inflammation. Low-grade inflammation is also associated with schizophrenia. Adipokine resistin is a biomarker involving several acute and chronic inflammatory states. However, the inflammatory role of resistin is so far inconclusive and studies in schizophrenia are scanty.

AIMS

The aim of the present study was to explore the role of serum resistin as an inflammatory marker in patients with schizophrenia on clozapine treatment.

METHODS

Associations between serum levels of resistin and some other selected cytokines/adipokines (adiponectin, leptin, adipsin, IL-6, IL-1Ra, TNF-α, hs-CRP) and metabolic markers in 190 patients with schizophrenia on clozapine treatment were studied using a cross-sectional study design.

RESULTS

Among male patients especially, smokers had higher levels of resistin than non-smokers, and among smokers resistin levels were associated with IL-1Ra and hs-CRP levels. In the whole patient group levels of resistin associated with levels of IL-1Ra, and among male patients with low HDL-cholesterol.

CONCLUSIONS

Resistin is a biomarker of systemic inflammation associated with smoking among patients with schizophrenia on clozapine treatment. Resistin might have a role as a marker of cardiovascular comorbidity.

Predictors of smoking reduction outcomes in a sample of 287 patients with schizophrenia spectrum disorders

Many studies have investigated whether a type of antipsychotics or type of adjuvant is associated with smoking reduction in patients with schizophrenia. However, there has been no study exploring a comprehensive range of factors related to smoking reduction in schizophrenia patients. We analyzed a dataset of 287 smoking patients with schizophrenia who participated in an 8-week open-label study with high- (n = 90) or low-dose nicotine dermal patches (n = 132) or bupropion (n = 65). A logistic regression model and a linear mixed model were used to explore factors associated with the outcomes of smoking cessation and reduction, i.e., the number of cigarettes smoked and the level of nicotine dependence. The total cessation rate was 6.3 % (18/287). There were no significant predictors of cessation. The time effect of reduction was significant during the program (p = 0.001). Type of antipsychotics (p = 0.018), readiness to quit (p = 0.014), baseline number of cigarettes smoked per day (p = 0.001), and nicotine dependence level (p = 0.001) were significantly associated with smoking reduction. Patients on first-generation antipsychotics (n = 129) or clozapine (n = 70) reduced their smoking more than those on non-clozapine second-generation antipsychotics (n = 74). Patients in the preparation stage (n = 97) or in the contemplation (n = 70) reduced their smoking more than those in the precontemplation stage (n = 120). The mechanisms of tobacco addiction need to be better understood for further development of effective cessation programs in patients with schizophrenia.

Physical and mental health burden in cases of bipolar disorder classified as current, former, or non-tobacco smokers

BACKGROUND

Tobacco smoking increases the global burden of bipolar disorder (BD). We examined markers of physical and mental health that are associated with tobacco smoking, controlling for confounders that have not always been considered in previous studies of BD.

METHODS

Over 600 individuals with BD I or II referred to the French Network for bipolar disorder (FACE-BD) who completed standardized assessments, and could be reliably classified as current (CS) or former smokers (FS), were compared with those who were never smokers (NS) on: BD symptom load and psychiatric comorbidities; prevalence of alcohol and substance use disorders (ASUD); medication usage; functioning and physical health parameters. The bivariate and multivariate analyses took into account age and gender.

RESULTS

300 cases (49%) were CS, 78 (13%) FS and 238 (39%) had never smoked. Rates were similar across genders regardless of BD subtype. Compared with NS, CS were more likely to have an ASUD (Odds Ratio (OR) 5.18), BD I (OR 2.09), and lower abdominal obesity (OR 0.97), and FS were more likely to have an ASUD (OR 6.32) and higher abdominal obesity (OR 1.03).

LIMITATIONS

The sample comprised of white Europeans; the FS subgroup was relatively small and we did not apply any statistical correction for the bivariate analyses.

CONCLUSIONS

The increased risk of physical and mental health burden in CS and FS compared to NS represents avoidable morbidity in BD. This study offers support to the argument that individuals with BD should be routinely offered support to prevent or stop tobacco smoking.

Nicotine Withdrawal, Relapse of Mental Illness, or Medication Side-Effect? Implementing a Monitoring Tool for People With Mental Illness Into Quitline Counseling

BACKGROUND

Smokers with mental illness and their health care providers are often concerned that smoking cessation will worsen mental health. Smokers with mental illness tend to be more nicotine-dependent and experience more severe symptoms of nicotine withdrawal, some of which are difficult to distinguish from psychiatric symptoms. In addition, smoking cessation can increase the blood levels and hence side effects of some psychotropic medications. Improved monitoring of nicotine withdrawal and medication side effects may help distinguish temporary withdrawal symptoms from psychiatric symptoms and facilitate targeted treatment to help smokers with mental illness manage the acute phase of nicotine withdrawal.

OBJECTIVE

The aim of this research was to examine the acceptability and feasibility to quitline counselors of implementing structured assessments of nicotine withdrawal and common medication side effects in people with mental illness who are quitting smoking using a telephone smoking cessation service.

METHODS

Monitoring involves administering (once pre-cessation and at each contact post-cessation) (1) the Minnesota Nicotine Withdrawal Scale, assessing eight symptoms: anger, anxiety, depression, cravings, difficulty concentrating, increased appetite, insomnia, and restlessness and (2) an adverse side effects checklist of 5 to 10 symptoms, for example, dry mouth and increased thirst. Following a 1-day update training in mental health, quitline counselors were asked to offer these assessments to callers disclosing mental illness in addition to usual counseling. Group interviews with counselors were conducted 2 months later to examine implementation barriers and benefits.

RESULTS

Barriers included awkwardness in integrating a new structured practice into counseling, difficulty in limiting some callers to only the content of new items, and initial anxieties about how to respond to changes in some symptoms. Benefits included the ability to provide objective feedback on changes in symptoms, as this identified early benefits of quitting, provided reassurance for clients, and provided an opportunity for early intervention where symptoms worsened.

CONCLUSIONS

Structured monitoring of withdrawal symptoms and medication side effects was able to be integrated into the quitline's counseling and was valued by counselors and clients. Given evidence of its benefits in this limited pilot study, we recommend it be considered for larger-scale adoption by quitlines.

Predictors of the Perception of Smoking Health Risks in Smokers With or Without Schizophrenia

OBJECTIVE

This study sought to examine the predictors of health risk perception in smokers with or without schizophrenia.

METHODS

The health risk subscale from the Smoking Consequences Questionnaire was dichotomized and used to measure health risk perception in smokers with (n = 67) and without schizophrenia (n = 100). A backward stepwise logistic regression was conducted using variables associated at the bivariate level to determine multivariate predictors.

RESULTS

Overall, 62.5% of smokers without schizophrenia and 40.3% of smokers with schizophrenia completely recognize the health risks of smoking (p ≤ .01). Multivariate predictors for smokers without schizophrenia included: sex (Exp (B) = .3; p < .05), Smoking Consequences Questionnaire state enhancement (Exp (B) = .69; p < .01), and craving relief (Exp (B) = 1.8; p < .01). Among smokers with schizophrenia, predictors were education (Exp (B) = .7; p < .05), nicotine dependence (Exp (B) = .5; p < .01), motivation to quit (Exp (B) = 1.8; p < .01), and Smoking Consequences Questionnaire craving relief (Exp (B) = 1.8; p < .01).

CONCLUSIONS

There was overlap and differences between predictors in smokers with and without schizophrenia. Commonly used techniques for education on the health consequences of cigarettes may work in smokers with schizophrenia, but intervention efforts specifically tailored to smokers with schizophrenia might be more efficacious.

Use of Electronic Nicotine Delivery Systems among Adults with Mental Health Conditions, 2015

Adults with mental health conditions (MHC) are especially likely to smoke and experience tobacco-related health disparities. Individuals with MHC may also use electronic nicotine delivery devices (ENDS) at disproportionately high rates. However, there is a relative dearth of knowledge regarding ENDS use among individuals with MHC. In a large representative sample of U.S. adults (n = 6051), associations between self-reported MHC diagnoses and ENDS use and susceptibility were examined, stratified by smoking status. Participants with MHC were approximately 1.5 times more likely to have used ENDS in their lifetime and almost twice as likely to currently use ENDS as those without MHC. MHC status was most strongly linked to higher ENDS use among former smokers, and former smokers with MHC were more likely to report using ENDS during past smoking quit attempts than those without MHC. Among participants who had not tried ENDS, former smokers with MHC were especially susceptible to future ENDS use. The potential advantage of ENDS for cessation purposes should be balanced with the risk of attracting former smokers with MHC to ENDS.

Smoking, Mental Illness, and Public Health

Tobacco use remains the leading preventable cause of death worldwide. In particular, people with mental illness are disproportionately affected with high smoking prevalence; they account for more than 200,000 of the 520,000 tobacco-attributable deaths in the United States annually and die on average 25 years prematurely. Our review aims to provide an update on smoking in the mentally ill. We review the determinants of tobacco use among smokers with mental illness, presented with regard to the public health HAVE framework of “the host” (e.g., tobacco user characteristics), the “agent” (e.g., nicotine product characteristics), the “vector” (e.g., tobacco industry), and the “environment” (e.g., smoking policies). Furthermore, we identify the significant health harms incurred and opportunities for prevention and intervention within a health care systems and larger health policy perspective. A comprehensive effort is warranted to achieve equity toward the 2025 Healthy People goal of reducing US adult tobacco use to 12%, with attention to all subgroups, including smokers with mental illness.

Smoking and the Reduced Life Expectancy of Individuals With Serious Mental Illness

INTRODUCTION

People with serious mental illness experience substantially reduced life expectancy, likely due in part to their higher smoking rates relative to the general population. However, the extent to which smoking affects their life expectancy, independent of mental illness, is unknown. This study quantifies the potential contribution of smoking to reduced life expectancy among individuals with serious psychological distress (SPD), a measure that screens for serious mental illness in national surveys.

METHODS

A cohort of 328,110 U.S. adults was examined using the 1997-2009 National Health Interview Surveys linked to the 2011 National Death Index. Cox models were used to estimate mortality hazard ratios for current smoking, former smoking, and SPD and construct life tables by smoking and SPD status. The smoking-attributable fraction of deaths by SPD status was calculated. Analyses were conducted in 2015.

RESULTS

Among those with SPD, being a current smoker doubles the risk of death. Current smokers with SPD lose 14.9 years of life relative to never smokers without SPD. Among never smokers, having SPD reduces life expectancy by 5.3 years. Thus, smoking may account for up to two thirds of the difference in life expectancy between smokers with SPD and never smokers without SPD. One third of deaths among those with SPD can be attributed to smoking.

CONCLUSIONS

The life expectancy difference between current smokers with SPD and never smokers without SPD is primarily due to smoking. Aiding individuals with serious mental illness to avoid smoking will translate into sizeable gains in life expectancy.

A behavioral economic perspective on smoking persistence in serious mental illness

Serious mental illness (SMI) is associated with disproportionately high rates of cigarette smoking. The identification of factors that contribute to persistent smoking in people with SMI may lead to the development and adoption of tobacco control policies and treatment approaches that help these smokers quit. This commentary examines factors underlying smoking persistence in people with SMI from the perspective of behavioral economics, a discipline that applies economic principles to understanding drug abuse and dependence. Studies, conducted in the Northeastern US within the past 30years, that compare the reinforcing effects of nicotine and the costs of smoking in smokers with and without schizophrenia and depression are discussed, and interventions that may reduce the reinforcing efficacy of nicotine and increase the costs of smoking in people with SMI are described.

Varenicline for smoking cessation and reduction in people with severe mental illnesses: systematic review and meta-analysis

AIMS

To determine the effectiveness and safety of varenicline in treating tobacco dependence in patients with severe mental illness.

DESIGN

A systematic review and meta-analysis of randomised controlled trials that compared varenicline with a placebo or an alternative intervention for smoking cessation or reduction.

SETTING

Both in- and out-patient settings in any country.

PARTICIPANTS

Adult patients aged 18 years and over with any type of severe mental illness. The systematic review included eight studies comprising 398 participants.

MEASURES

Primary outcome measures were (1) smoking cessation, (2) smoking reduction measured by changes in the number of cigarettes smoked per day and (3) number of psychiatric adverse events, which were collected at the end of treatment.

FINDINGS

The random-effect pooled estimates from the five studies that reported smoking-related outcomes found that varenicline is statistically superior to placebo in smoking cessation [risk ratios 4.33; 95% confidence interval (CI) = 1.96-9.56], and smoking reduction was higher in varenicline groups (mean reduced daily cigarettes was 6.39; 95% CI = 2.22-10.56). There is no significant difference regarding neuropsychiatric and other adverse events.

CONCLUSIONS

Varenicline appears to be significantly more effective than placebo in assisting with smoking cessation and reduction in people with severe mental illness. There appears to be no clear evidence that varenicline was associated with an increased risk of neuropsychiatric or other adverse events compared with placebo.

Modelling intentions to provide smoking cessation support among mental health professionals in the Netherlands

BACKGROUND

Tobacco use prevalence is elevated among people with mental illnesses, leading to elevated rates of premature smoking-related mortality. Opportunities to encourage smoking cessation among them are currently underused by mental health professionals. In this paper, we aim to explore mechanisms to invigorate professionals' intentions to help patients stop smoking.

METHODS

Data stem from a recent staff survey on the provision of smoking cessation support to patients with mental illnesses in the Netherlands. Items and underlying constructs were based on the theory of planned behaviour and literature on habitual behaviour. Data were weighted and only data from staff members with regular patient contact (n = 506) were included. Descriptive statistics of the survey items are presented and in a second step using structural equation modelling (SEM), we regressed the latent variables attitudes, subjective norms (SN), perceived behavioural control (PBC), past cessation support behaviour (PB) and current smoking behaviour on intentions to provide support. In optimisation steps, models comprising a subset of this initial model were evaluated.

RESULTS

A sample of 506 mental health workers who had direct contact with patients completed the survey. The majority of them were females (70.0 %), respondents had an average age of 42.5 years (SD = 12.0). Seventy-five percent had at least a BSc educational background. Of the respondents, 76 % indicated that patients should be encouraged more to quit smoking. Respondents were supportive to train their direct colleagues to provide cessation support more often (71 %) and also supported the involvement of mental health care facilities in providing cessation support to patients (69 %). The majority of the respondents feels capable to provide cessation support (66 %). Two thirds of the respondents wants to provide support, however only a minority (35 %) intends to actually do so during the coming year. Next, using SEM an acceptable fit was found of the constructs derived from the theory of planned behaviour and literature on habitual behaviour to the weighted data (χ (2) (322) = 1188, p < .001; RMSEA = 0.067; CFI = 0.983), after removal of insignificant latent variables (SN and current smoking) and inclusion of covariates. Attitudes, PBC and PB of staff are the strongest identified correlates of intention toward providing cessation support to patients. SN and staff smoking behaviour were found to be weaker, non-significant correlates.

CONCLUSIONS

To nudge staff towards providing cessation support to people with mental illnesses one should aim at influencing attitudes and perceived behavioural control.

Effects of 6-Week Use of Reduced-Nicotine Content Cigarettes in Smokers With and Without Elevated Depressive Symptoms

BACKGROUND

The FDA recently acquired regulatory authority over tobacco products, leading to renewed interest in whether reducing the nicotine content of cigarettes would reduce tobacco dependence in the United States. Given the association between depressive symptoms and cigarette smoking, it is important to consider whether smokers with elevated depressive symptoms experience unique benefits or negative consequences of nicotine reduction.

METHODS

In this secondary analysis of a randomized clinical trial that examined the effects of cigarettes varying in nicotine content over a 6-week period in non-treatment-seeking smokers, we used linear regression to examine whether baseline depressive symptom severity (scores on the Center for Epidemiologic Studies Depression Scale [CES-D]) moderated the effects of reduced-nicotine content (RNC) cigarettes, relative to normal-nicotine content (NNC) cigarettes, on smoking rates, depressive symptom severity, and related subjective and physiological measures.

RESULTS

Of the 717 participants included in this analysis, 109 (15.2%) had CES-D scores ≥ 16, indicative of possible clinical depression. Relative to NNC cigarettes, RNC cigarettes reduced smoking rates, nicotine dependence, and cigarette craving, and these effects were not significantly moderated by baseline CES-D score. A significant interaction between baseline CES-D score and cigarette condition on week 6 CES-D score was observed (p < .05); among those with CES-D scores ≥ 16 at baseline, those assigned to RNC cigarettes had lower week 6 CES-D scores than those assigned to NNC cigarettes. Among those in the lowest nicotine content conditions, biochemically confirmed compliance with the RNC cigarettes was associated with an increase in CES-D score for those with baseline CES-D scores < 16 and no change in CES-D score for those with baseline CES-D scores ≥ 16.

CONCLUSIONS

These findings provide initial evidence that a reduced-nicotine standard for cigarettes may reduce smoking, without worsening depressive symptoms, among smokers with elevated depressive symptoms.

IMPLICATIONS

This secondary analysis of a recent clinical trial examined whether depressive symptom severity moderated the effects of reduced-nicotine cigarettes on smoking and depressive symptoms. Results indicate that, regardless of baseline depressive symptoms, participants randomized to reduced-nicotine cigarettes had lower smoking rates, nicotine intake, nicotine dependence, and craving at week 6 post-randomization than those assigned to normal-nicotine cigarettes. In participants with higher baseline depressive symptoms, those assigned to reduced-nicotine cigarettes had lower week 6 depressive symptoms than those assigned to normal-nicotine cigarettes. These results suggest that a nicotine reduction policy could have beneficial effects for smokers, regardless of depressive symptom severity.

Making the journey with me: a qualitative study of experiences of a bespoke mental health smoking cessation intervention for service users with serious mental illness

BACKGROUND

Smoking is one of the major modifiable risk factors contributing to early mortality for people with serious mental illness. However, only a minority of service users access smoking cessation interventions and there are concerns about the appropriateness of generic stop-smoking services for this group. The SCIMITAR (Smoking Cessation Intervention for Severe Mental Ill-Health Trial) feasibility study explored the effectiveness of a bespoke smoking cessation intervention delivered by mental health workers. This paper reports on the nested qualitative study within the trial.

METHODS

Qualitative semi-structured interviews were conducted with 13 service users receiving the intervention and 3 of the MHSCPs (mental health smoking cessation practitioners) delivering the intervention. Topic guides explored the perceived acceptability of the intervention particularly in contrast to generic stop-smoking services, and perceptions of the implementation of the intervention in practice. Transcripts were analysed using the Constant Comparative Method.

RESULTS

Generic services were reported to be inappropriate for this group, due to concerns over stigma and a lack of support from health professionals. The bespoke intervention was perceived positively, with both practitioners and service users emphasising the benefits of flexibility and personalisation in delivery. The mental health background of the practitioners was considered valuable not only due to their increased understanding of the service users' illness but also due to the more collaborative relationship style they employed. Challenges involved delays in liaising with general practitioners and patient struggles with organisation and motivation, however the MHSCP was considered to be well placed to address these problems.

CONCLUSION

The bespoke smoking cessation intervention was acceptable to service users and the both service users and practitioners reported the value of a protected mental health worker role for delivering smoking cessation to this group. The results have wider implications for understanding how to achieve integrated and personalised care for this high-risk population and further underscore the need for sensitised smoking cessation support for people with serious mental illness.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN79497236 . Registered 3(rd) July 2009.

Effectiveness of an intervention in increasing the provision of preventive care by community mental health services: a non-randomized, multiple baseline implementation trial

BACKGROUND

Relative to the general population, people with a mental illness are more likely to have modifiable chronic disease health risk behaviours. Care to reduce such risks is not routinely provided by community mental health clinicians. This study aimed to determine the effectiveness of an intervention in increasing the provision of preventive care by such clinicians addressing four chronic disease risk behaviours.

METHODS

A multiple baseline trial was undertaken in two groups of community mental health services in New South Wales, Australia (2011-2014). A 12-month practice change intervention was sequentially implemented in each group. Outcome data were collected continuously via telephone interviews with a random sample of clients over a 3-year period, from 6 months pre-intervention in the first group, to 6 months post intervention in the second group. Outcomes were client-reported receipt of assessment, advice and referral for tobacco smoking, harmful alcohol consumption, inadequate fruit and/or vegetable consumption and inadequate physical activity and for the four behaviours combined. Logistic regression analyses examined change in client-reported receipt of care.

RESULTS

There was an increase in assessment for all risks combined following the intervention (18 to 29 %; OR 3.55, p = 0.002: n = 805 at baseline, 982 at follow-up). No significant change in assessment, advice or referral for each individual risk was found.

CONCLUSIONS

The intervention had a limited effect on increasing the provision of preventive care. Further research is required to determine how to increase the provision of preventive care in community mental health services.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12613000693729.

A Review of Impact of Tobacco Use on Patients with Co-occurring Psychiatric Disorders

Consumption of tobacco has been a worldwide problem over the past few decades due to the highly prevalent tobacco-attributable complications. Tobacco use has also been found to be more prevalent in patients with psychiatric disorders. Therefore, we conducted this review about the impact of tobacco use on co-occurring psychiatric disorders. Various facets of this interaction between tobacco use among those with co-occurring psychiatric disorders have been explored. It has been found that people with psychiatric disorders have a higher chance of currently smoking tobacco and lesser chance of cessation. Tobacco use and mental disorders continue to share a complex relationship that has been further evolving after the change in the pattern of tobacco use and also the advent of newer modalities of treatment. However, at the same time, it is believed that cessation of smoking may lead to improvement in the symptoms of mental illness.

Medications between psychiatric and addictive disorders

INTRODUCTION

Many epidemiological studies have revealed a frequent co-occurrence of psychiatric and substance use disorders. The term used in the literature to refer to this co-occurrence is dual diagnosis. The high prevalence of dual diagnosis has led physicians to observe the effects of medication prescribed to treat psychiatric disorders on the co-occurring substance use disorder and vice versa. The concept of medications between psychiatric and addictive disorders stems from these clinical observations, alongside which, however, it has developed from the observation that both psychiatric and substance use disorders share common neurobiological pathways and trigger common cognitive disorders. This has led researchers to develop medications on the basis of neurobiological and cognitive rationales.

MATERIAL AND METHOD

In our article, we review peculiar medications based on neurobiological and cognitive rationales and that have an impact in both psychiatric and addictive disorders.

RESULTS

We highlight how interesting these new prescriptions are for clinical observation and for the treatment of patients suffering from dual diagnosis.

CONCLUSION

We then go on to discuss the interest in them from the perspective of clinical practice and clinical research, in that the development of medications to treat dual diagnosis helps to further our knowledge of both psychiatric and substance use disorders.

Cardiovascular diseases among patients with schizophrenia

The presence of comorbid physical illnesses especially, cardiovascular diseases (CVD) in schizophrenia is a growing area of concern in recent years. In order to reduce disease burden, to improve quality of life and to provide holistic care, it is important to know about the relationship between schizophrenia and CVD. The objective of this review is to explore the extent of CVD problems, relevant risk factors and potential measures for early diagnosis and prevention of CVD among patients with schizophrenia. Worldwide studies show that patients with schizophrenia have a higher mortality and lower life expectancy than the general population. CVD is the leading cause of increased mortality in schizophrenia. Common CVD risk factors in schizophrenia include metabolic syndrome, sedentary behaviour, tobacco smoking, effects of antipsychotics, long chain omega-3 fatty acid deficiency and shared genetics between CVD and schizophrenia. The potential methods for early detection and prevention of CVD in schizophrenia are also discussed. Though the patients with schizophrenia form a high risk group for CVD, consensus guidelines for early detection and prevention of CVD in schizophrenia are lacking. Comorbidity of CVD in schizophrenia needs more serious attention by clinicians and researchers.

Mortality in schizophrenia and bipolar disorder: Clinical and serological predictors

Persons with schizophrenia and with bipolar disorder have a reduced life expectancy due largely to death from natural causes. The reasons for this increased mortality have not been completely defined. We prospectively assessed a cohort of persons with schizophrenia and one with bipolar disorder with a clinical evaluation and a blood sample from which immune and infectious disease markers were measured. Mortality was determined with data from the National Death Index following a period of up to 14years. We examined the role of demographic, clinical, and serological factors on mortality in bivariate and multivariate models. A total of 43/710 (6.1%) persons with schizophrenia and 12/406 (3.0%) with bipolar disorder died of natural causes. In the schizophrenia group, mortality was predicted by the following variables in a multivariate model: cigarette smoking (RR=6.93, 95% CI 1.59, 30.1, p=0.0099); autoimmune disorder (RR=8.08, 95% CI 2.50, 26.1, p=0.00047); gastrointestinal disorder (GI) (RR=3.53, 95% CI 1.43, 8.69 p=0.0061); and reduced maternal education (RR=0.84, 95% CI 0.72, 0.97), p=0.018. The combination of smoking and an autoimmune disorder yielded an unadjusted relative risk of 18.1 for mortality, and the combination of smoking and a GI disorder an unadjusted relative risk of 9.45, compared with individuals with neither risk factor. In the bipolar disorder group, significant bivariate predictors of mortality included lower cognitive score (RR=0.95, p=.0085) and the presence of type 1 or 2 diabetes (RR=3.90, p=.026). Given the extraordinary high risk of death due to smoking in schizophrenia, smoking cessation remains an urgent priority.

Responses to Tobacco Smoking-Related Health Messages in Young People With Recent-Onset Schizophrenia

Virtually no research has examined the responses of youth with recent-onset psychosis (ROP) to smoking-related health warnings. We examined predictors of response and tested hypotheses that participants with ROP would (a) assess warnings as less effective than a healthy comparison (HC) group, and (b) assess video warnings as more effective than pictures. ROP participants (n = 69) had <2 years of prior antipsychotic treatment; the HC group (n = 79) had no major mental illness. Participants viewed 10 pictorial warnings, 8 videos depicting similar messages, and were interviewed regarding tobacco use, health literacy, and smoking knowledge. We assessed response at baseline and at 4-week follow-up. ROP participants were more likely than HC to smoke tobacco (49.3% vs 10.1%) and had lower levels of health literacy and smoking-related knowledge. Cannabis was used by 46.4% of ROP participants. Effectiveness ratings were high for both picture and video warnings with no differences between media. ROP participants compared to HC and nonsmokers compared to smokers were more likely to perceive warnings as effective. Effectiveness was associated with negative affect and greater emotional arousal. We assessed 33 smokers at follow-up; 5 (15%) identified as nonsmokers, 15 (45%) made a quit attempt, and 16 (49%) reported that the warnings influenced their smoking. Results indicate that young people with psychotic disorders respond favorably to health warnings. Effective messages depict health consequences clearly, elicit negative emotions, and may impact smoking behavior. Future research is needed to understand the effects of mode of presentation and message comprehension on smoking behavior.

Smoking cessation and reduction in people with chronic mental illness

The high prevalence of cigarette smoking and tobacco related morbidity and mortality in people with chronic mental illness is well documented. This review summarizes results from studies of smoking cessation treatments in people with schizophrenia, depression, anxiety disorders, and post-traumatic stress disorder. It also summarizes experimental studies aimed at identifying biopsychosocial mechanisms that underlie the high smoking rates seen in people with these disorders. Research indicates that smokers with chronic mental illness can quit with standard cessation approaches with minimal effects on psychiatric symptoms. Although some studies have noted high relapse rates, longer maintenance on pharmacotherapy reduces rates of relapse without untoward effects on psychiatric symptoms. Similar biopsychosocial mechanisms are thought to be involved in the initiation and persistence of smoking in patients with different disorders. An appreciation of these common factors may aid the development of novel tobacco treatments for people with chronic mental illness. Novel nicotine and tobacco products such as electronic cigarettes and very low nicotine content cigarettes may also be used to improve smoking cessation rates in people with chronic mental illness.

Development of a Conceptual Model for Smoking Cessation: Physical Activity, Neurocognition, and Executive Functioning

PURPOSE

Considerable research has shown adverse neurobiological effects of chronic alcohol use, including long-term and potentially permanent changes in the structure and function of the brain; however, much less is known about the neurobiological consequences of chronic smoking, as it has largely been ignored until recently. In this article, we present a conceptual model proposing the effects of smoking on neurocognition and the role that physical activity may play in this relationship as well as its role in smoking cessation.

METHODS

Pertinent published peer-reviewed articles deposited in PubMed delineating the pathways in the proposed model were reviewed.

RESULTS

The proposed model, which is supported by emerging research, demonstrates a bidirectional relationship between smoking and executive functioning. In support of our conceptual model, physical activity may moderate this relationship and indirectly influence smoking behavior through physical activity-induced changes in executive functioning.

CONCLUSIONS

Our model may have implications for aiding smoking cessation efforts through the promotion of physical activity as a mechanism for preventing smoking-induced deficits in neurocognition and executive function.

Cancer and serious mental illness--patient, caregiver and professional perspectives: study protocol

AIM

To explore the experience of serious mental illness and cancer from the perspective of patients, significant others and healthcare professionals involved in their care.

BACKGROUND

Serious mental illness is associated with poorer cancer outcomes. Those suffering from this comorbidity receive fewer specialist interventions and die earlier than the general population. Prior qualitative research in this area has comprised of a single study focussing on healthcare professionals and there is little evidence regarding the experiences of patients and caregivers.

DESIGN

A qualitative exploration using approximately 36 semi-structured interviews.

METHODS

Semi-structured digitally recorded interviews conducted with: adults living with serious mental illness and diagnosed with cancer; those providing them with informal support and care; and healthcare professionals. Questions will focus on the experience of having cancer and serious mental illness or caring for someone with this comorbidity, experiences of healthcare and priorities for patients and carers. Framework analysis will be used. Research Ethics Committee and Trust Research & Development approval was obtained. A steering group comprising six people with experience of either cancer or mental illness provided feedback and ratified the patient information sheets and interview schedules.

DISCUSSION

There is a paucity of research addressing stakeholder perspectives on the experience of cancer and of cancer services for people with serious mental illness. Dissemination of findings will inform practice relating to the care of an often neglected population, informing better support for their significant others and the professionals involved in their care.

How can we promote smoking cessation in people with schizophrenia in practice? A clinical overview

OBJECTIVE

High rates of smoking and nicotine dependence are associated with increased physical comorbidity and premature death in people with schizophrenia. We conducted a clinical overview to establish how smoking cessation should be promoted in practice.

METHOD

Systematic clinical review of major electronic databases from inception till November 2014.

RESULTS

A growing body of evidence supports pharmacological interventions to assist smoking cessation. The most promising evidence is for bupropion with several meta-analyses demonstrating its effectiveness. Currently, there is limited evidence demonstrating the effectiveness of nicotine replacement therapy (NRT) and varenicline, although this is likely to be due to the paucity of research. There are no consistent data to suggest that pharmacological interventions increase adverse events. Behavioural and psychosocial interventions also demonstrate promise, particularly when combined with pharmacotherapy. Careful monitoring of antipsychotic levels (in particular clozapine) is essential, and the promotion of physical activity may be useful to negate potential weight gain and diabetes risk following smoking cessation.

CONCLUSION

Evidence from systematic reviews and meta-analyses suggests that smoking cessation interventions are effective in people with schizophrenia, although more long-term research is required. Promoting smoking cessation should be given utmost priority in clinical practice, and we offer practical strategies to facilitate this.