Telephone Smoking-Cessation Counseling for Smokers in Mental Health Clinics: A Patient-Randomized Controlled Trial

Effectiveness and User Experience of a Smoking Cessation Chatbot: Mixed Methods Study Comparing Motivational Interviewing and Confrontational Counseling

BACKGROUND

Cigarette smoking poses a major public health risk. Chatbots may serve as an accessible and useful tool to promote cessation due to their high accessibility and potential in facilitating long-term personalized interactions. To increase effectiveness and acceptability, there remains a need to identify and evaluate counseling strategies for these chatbots, an aspect that has not been comprehensively addressed in previous research.

OBJECTIVE

This study aims to identify effective counseling strategies for such chatbots to support smoking cessation. In addition, we sought to gain insights into smokers' expectations of and experiences with the chatbot.

METHODS

This mixed methods study incorporated a web-based experiment and semistructured interviews. Smokers (N=229) interacted with either a motivational interviewing (MI)-style (n=112, 48.9%) or a confrontational counseling-style (n=117, 51.1%) chatbot. Both cessation-related (ie, intention to quit and self-efficacy) and user experience-related outcomes (ie, engagement, therapeutic alliance, perceived empathy, and interaction satisfaction) were assessed. Semistructured interviews were conducted with 16 participants, 8 (50%) from each condition, and data were analyzed using thematic analysis.

RESULTS

Results from a multivariate ANOVA showed that participants had a significantly higher overall rating for the MI (vs confrontational counseling) chatbot. Follow-up discriminant analysis revealed that the better perception of the MI chatbot was mostly explained by the user experience-related outcomes, with cessation-related outcomes playing a lesser role. Exploratory analyses indicated that smokers in both conditions reported increased intention to quit and self-efficacy after the chatbot interaction. Interview findings illustrated several constructs (eg, affective attitude and engagement) explaining people's previous expectations and timely and retrospective experience with the chatbot.

CONCLUSIONS

The results confirmed that chatbots are a promising tool in motivating smoking cessation and the use of MI can improve user experience. We did not find extra support for MI to motivate cessation and have discussed possible reasons. Smokers expressed both relational and instrumental needs in the quitting process. Implications for future research and practice are discussed.

'Quitlink': Outcomes of a randomised controlled trial of peer researcher facilitated referral to a tailored quitline tobacco treatment for people receiving mental health services

OBJECTIVE

The aim of this study was to test the effectiveness of a tailored quitline tobacco treatment ('Quitlink') among people receiving support for mental health conditions.

METHODS

We employed a prospective, cluster-randomised, open, blinded endpoint design to compare a control condition to our 'Quitlink' intervention. Both conditions received a brief intervention delivered by a peer researcher. Control participants received no further intervention. Quitlink participants were referred to a tailored 8-week quitline intervention delivered by dedicated Quitline counsellors plus combination nicotine replacement therapy. The primary outcome was self-reported 6 months continuous abstinence from end of treatment (8 months from baseline). Secondary outcomes included additional smoking outcomes, mental health symptoms, substance use and quality of life. A within-trial economic evaluation was conducted.

RESULTS

In total, 110 participants were recruited over 26 months and 91 had confirmed outcomes at 8 months post baseline. There was a difference in self-reported prolonged abstinence at 8-month follow-up between Quitlink (16%, n = 6) and control (2%, n = 1) conditions, which was not statistically significant (OR = 8.33 [0.52, 132.09] p = 0.131 available case). There was a significant difference in favour of the Quitlink condition on 7-day point prevalence at 2 months (OR = 8.06 [1.27, 51.00] p = 0.027 available case). Quitlink costs AU$9231 per additional quit achieved.

CONCLUSION

The Quitlink intervention did not result in significantly higher rates of prolonged abstinence at 8 months post baseline. However, engagement rates and satisfaction with the 'Quitlink' intervention were high. While underpowered, the Quitlink intervention shows promise. A powered trial to determine its effectiveness for improving long-term cessation is warranted.

The effectiveness of a telephone smoking cessation program in mental health clinic patients by level of mental well-being and functioning: a secondary data analysis of a randomized clinical trial

BACKGROUND

Few studies have examined the effectiveness of telephone smoking cessation interventions by severity of behavioral health symptoms. Using data from a telephone counseling study, we examined whether abstinence rates varied by level of behavioral health symptoms.

METHODS

The parent study recruited adults who smoke cigarettes (N = 577) referred by mental health providers at six Veterans Health Administration facilities. Participants were randomized to specialized telephone counseling (intervention) or state Quitline referral (control). Participants completed assessments at baseline and 6 months, including the BASIS-24, a self-report measure of behavioral health symptoms and functioning. We used the BASIS-24 median to dichotomize participants as having high or low scores. The primary outcome was 30-day self-reported abstinence at 6 months. We compared groups on outcomes by logistic regression and performed an interaction effect analysis between treatment assignment and groups.

RESULTS

At baseline, those with high behavioral health symptoms scores reported heavier nicotine dependence and more sedative and/or antidepressant use, compared to participants with low behavioral health symptoms. At 6 months, participants with low behavioral health symptoms scores in the intervention reported higher rates of 30-day abstinence compared to those in the control arm (26% vs 13%, OR = 2.3, 95% CI = 1.8, 2.9). People with high behavioral health symptoms scores reported no difference in 30-day abstinence between the treatment assignments at 6 months (12% vs. 13%, OR = 1.1, 95% CI = 0.6, 2.0).

CONCLUSIONS

Only participants with low behavioral health symptoms scores reported higher abstinence rates in the intervention compared to the state Quitline. Future research can examine alternative approaches for people with worse mental well-being and functioning.

TRIAL REGISTRATION

The parent study is registered at www.

CLINICALTRIALS

gov NCT00724308.

Integrating the "Quit and Stay Quit Monday" Model into Smoking Cessation Services for Smokers with Mental Health Conditions: A Pilot Randomized Controlled Trial

Introduction

People with mental health conditions (MHCs) are less likely to achieve long-term abstinence than people without MHCs. The Quit and Stay Quit Monday (QSQM) model offers a long-term approach to treating tobacco use by encouraging people to quit, requit, or recommit to quit smoking every Monday.

Aim

To evaluate the efficacy, patient satisfaction, and patient engagement with an intervention that integrated the QSQM model into multicomponent smoking cessation services among people with an MHC.

Methods

This was a randomized controlled pilot trial. Eligibility criteria were as follows: (1) ≥18 years old, (2) smoked a cigarette in the past 30 days, (3) diagnosis of an ICD-10 MHC, (4) interest in quitting smoking, (5) able to receive services in English, and (5) had an active email and a cell phone. The intervention group (n = 33) received QSQM-focused telephone coaching, a weekly QSQM email newsletter, a SmokefreeTXT anchored around a Monday quit date, and 4 weeks of nicotine replacement therapy (NRT). The control group (n = 36) received information about contacting their state Quitline for usual services. Primary outcomes were self-reported quit attempts, 7-day abstinence, and intervention satisfaction at 3 months.

Results

Twenty-four participants (73%) in the intervention group began telephone coaching, 26 (79%) enrolled in the QSQM email newsletter, 19 (58%) enrolled in SmokefreeTXT, and 15 (46%) used NRT. Using a penalized intent-to-treat approach, quit attempts in the intervention and control groups were 63.6% and 38.9% (OR 2.75, 95% CI 1.03-7.30), respectively. Seven-day abstinence in the two groups was 12.1% and 5.6% (OR 2.35, 95% CI 0.40-13.74), respectively. Of the 15 intervention group participants who set a quit date during the intervention, 13 (86.7%) selected a Monday quit day. Qualitative interviews revealed positive participant experiences with picking a Monday quit day. On follow-up surveys, 89.5%, 69.3%, and 64.3% of intervention participants reported that the counseling, QSQM email, and text messaging, respectively, were very or somewhat helpful.

Conclusions

The QSQM model was acceptable and potentially efficacious among people with MHCs, but intervention engagement and satisfaction were modest. Future research should adapt or develop new QSQM delivery approaches to improve patient engagement and potential efficacy of the model. This trial is registered with clinicaltrials.gov (NCT04512248).

Standardizing Tobacco Cessation Counseling Using the 5 A's Intervention

BACKGROUND

Tobacco use is the leading cause of preventable death due to cardiovascular disease.

LOCAL PROBLEM

Tobacco cessation counseling (TCC) is varied among providers, leading to suboptimal willingness to make a quit attempt.

METHODS

We used a quality improvement framework to pilot the 5 A's for TCC from April 2021 to August 2021 in our outpatient cardiology clinic.

INTERVENTIONS

Providers implemented TCC using the 5 A's intervention. Patient follow-up phone calls were conducted 30 days after receiving TCC.

RESULTS

Of 629 patient encounters, the mean TCC rate increased by 27.5%, and the mean reported cessation rates improved by 3.9%. Variation among providers decreased for TCC rates when they used the 5 A's intervention.

CONCLUSIONS

The 5 A's intervention standardized TCC efforts. Using the 5 A's led to an increase in patients who reported smoking cessation 30 days after TCC was received.

Feasibility Pilot Study of an Opioid Helpline for Individuals at High Risk for Opioid Use Disorder

BACKGROUND

Evidence suggests that educational interventions delivered by healthcare providers can be effective in altering patients' attitudes toward pain management and in referral to addiction treatment when appropriate. Time constraints during visits limit the delivery of such important interventions.

OBJECTIVE

This study aims to explore the feasibility and perceived value of an opioid helpline that provides resources to individuals suffering from or at risk for opioid use disorder.

METHODS

We developed a helpline with a toll-free number "1-877 OPIOIDS (6437)" established through the University of Virginia, which runs Monday through Friday from 8:30 am to 5 pm and is answered by a live answering service after hours. The helpline offered a range of resources including opioid pain medication education, signs of overdose or withdrawal, addiction treatment options, and connection to treatment services. The helpline was supported by outreach efforts to surrounding counties in Virginia. Questionnaires on perceived usefulness were sent to callers and providers who used or offered the helpline in their clinics. Survey data were analyzed to identify trends.

RESULTS

Thirty-one consented individuals of 166 contacts were included in the study. Although participants were referred to the helpline through a variety of sources, most were referred by a physician (38.7%). Most participants rated the helpline's helpfulness with the highest satisfaction score (81.5%). Most individuals seeking addiction treatment found the helpline to be useful, whereas those referred by their respective physician to gain more information about their opioid use and prevent escalation to addiction felt it was an unnecessary step.

CONCLUSIONS

Our pilot study demonstrated that a helpline could be an additional tool to combat the opioid crisis. Individual callers rated the intervention favorably. Our study shows that the most substantial area of satisfaction for our participants is being able to reach a live person when in need.

Integrating Financial Coaching and Referrals into a Smoking Cessation Program for Low-income Smokers: a Randomized Waitlist Control Trial

BACKGROUND

Financial distress is a barrier to cessation among low-income smokers.

OBJECTIVE

To evaluate an intervention that integrated financial coaching and benefits referrals into a smoking cessation program for low-income smokers.

DESIGN

Randomized waitlist control trial conducted from 2017 to 2019.

PARTICIPANTS

Adult New York City residents were eligible if they reported past 30-day cigarette smoking, had income below 200% of the federal poverty level, spoke English or Spanish, and managed their own funds. Pregnant or breastfeeding people were excluded. Participants were recruited from two medical centers and from the community.

INTERVENTION

The intervention (n = 208) offered smoking cessation coaching, nicotine replacement therapy, money management coaching, and referral to financial benefits and empowerment services. The waitlist control (n=202) was usual care during a 6-month waiting period.

MAIN MEASURES

Treatment engagement, self-reported 7-day abstinence, and financial stress at 6 months.

KEY RESULTS

At 6 months, intervention participants reported higher abstinence (17% vs. 9%, P=0.03), lower stress about finances (β, -0.8 [SE, 0.4], P=0.02), and reduced frequency of being unable to afford activities (β, -0.8 [SE, 0.4], P=0.04). Outcomes were stronger among participants recruited from the medical centers (versus from the community). Among medical center participants, the intervention was associated with higher abstinence (20% vs. 8%, P=0.01), higher satisfaction with present financial situation (β, 1.0 [SE, 0.4], P=0.01), reduced frequency of being unable to afford activities (β, -1.0 [SE, 0.5], P=0.04), reduced frequency in getting by paycheck-to-paycheck (β, -1.0 [SE, 0.4], P=0.03), and lower stress about finances in general (β, -1.0 [SE, 0.4], P = 0.02). There were no group differences in outcomes among people recruited from the community (P>0.05).

CONCLUSIONS

Among low-income smokers recruited from medical centers, the intervention produced higher abstinence rates and reductions in some markers of financial distress than usual care. The intervention was not efficacious with people recruited from the community.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03187730.

Severe Mental Illness and Cardiovascular Disease: JACC State-of-the-Art Review

People with severe mental illness, consisting of schizophrenia, bipolar disorder, and major depression, have a high burden of modifiable cardiovascular risk behaviors and conditions and have a cardiovascular mortality rate twice that of the general population. People with acute and chronic cardiovascular disease are at a higher risk of developing mental health symptoms and disease. There is emerging evidence for shared etiological factors between severe mental illness and cardiovascular disease that includes biological, genetic, and behavioral mechanisms. This state-of-the art review will describe the relationship between severe mental illness and cardiovascular disease, explore the factors that lead to poor cardiovascular outcomes in people with severe mental illness, propose strategies to improve the cardiovascular health of people with severe mental illness, and present areas for future research focus.

Predictors of Counseling Participation Among Low-Income People Offered an Integrated Intervention Targeting Financial Distress and Tobacco Use

Introduction

Although prevalence of smoking in the USA has been decreasing for decades, smoking rates among low-income individuals remain elevated. Theories from behavioral economics and prior research suggest that financial stress may contribute to the difficulty that low-income smokers face in quitting. The present work is a secondary analysis of a randomized controlled trial that incorporated financial coaching and social services referrals into smoking cessation treatment. Primary analyses showed that participants randomized to the intervention (N = 208) were significantly more likely not to smoke, to have lower financial stress, and to be able to afford leisure activities (p < .05) than were control participants (N = 202).

Methods

This paper investigates subgroup discrepancies in attendance of intervention sessions and in uptake of various components of this intervention through exploratory analysis.

Results

Analysis using logistic regression indicated that decreased age, not having received higher education, and having income less than $1000 per month were predictive of decreased counseling attendance (p < .05). Few demographic factors were predictive of uptake of counseling components among those who attended counseling.

Conclusions

These results can guide future efforts to increase participant engagement in the intervention.

Trial Registration

ClinicalTrials.gov Identifier: NCT03187730.

Implementing Chronic Care Model Treatments for Cigarette Dependence in Community Mental Health Clinics

Objective: Tobacco use is rarely addressed in community mental healthcare settings, despite its high prevalence among people with serious mental illness. The aim of the current study was to gather stakeholder feedback regarding the feasibility of chronic care management strategies for tobacco dependence in community mental health centers (CMHCs). Chronic care strategies evaluated included the 5 As (Ask about tobacco use, Advise users of tobacco to quit, Assess interest in cessation, Assist with cessation, and Arrange for follow-up) and proactive telephone outreach (reaching out to all users of tobacco to offer connection to tobacco cessation treatment). Methods: Using a semi-structured interview guide informed by the Practical Robust Implementation and Sustainability Model, we conducted individual semi-structured interviews with providers, leaders, and clients across two CMHCs. Our objectives were to capture their attitudes toward smoking cessation treatment, two chronic care model interventions (i.e., proactive outreach, the 5 As), and to determine the infrastructure needed to implement such interventions in their CMHCs. Thematic analysis was conducted by two independent coders to uncover pertinent themes. Results: Participants (n = 20) included nine providers, six leaders, and five clients. Thematic analysis revealed three major themes: (1) characteristics of recipients, (2) characteristics of the intervention, and (3) infrastructure needed for implementation and sustainability. Providers, leaders, and clients all reported that tobacco cessation treatment was rarely provided in CMHCs and expressed an interest in such treatments becoming more available. The 5 As and proactive outreach were viewed as feasible and acceptable to deliver and receive. Providers, leaders, and clients wanted support to connect clients with smoking cessation treatment. Providers and leaders requested a range of implementation supports, including didactic trainings, decision aids, performance feedback, and coaching on evidence-based tobacco cessation treatments for people with serious mental illness. Clients requested tobacco cessation resources, such as a cessation counseling provided at the CMHC and prescriptions for cessation medication. Conclusions: CMHC providers, leaders, and clients are interested in making tobacco cessation services more widely accessible and available. The feedback gathered in this study can be used to inform the delivery and implementation of guideline-adherent tobacco dependence care in CMHCs.

A novel opt-in vs opt-out approach to referral-based treatment of tobacco use in Veterans Affairs (VA) primary care clinics: A provider-level randomized controlled trial protocol

To determine whether an opt-out approach is effective for referral to treatment for tobacco use, we designed a clinical reminder for nurses in a primary care setting that provides a referral for patients who smoke cigarettes. We will use a two-arm, cluster-randomized design to assign nurses at the VA New York Harbor Healthcare System to test which mode of referral (opt-in vs opt-out) is more effective. All patients will be referred to evidence-based treatment for tobacco cessation including counseling from the New York State Quitline, and VetsQuit, a text messaging-based system for tobacco cessation counseling. We will measure patient engagement with the referral both in the short and long term to determine if referral modality had an impact on tobacco cessation treatment. We will also measure nurse engagement with the referral before, during, and after the implementation of the reminder to determine whether an opt-out approach is cost effective at the health system level. At the conclusion of this project, we expect to have developed and tested an opt-out system for increasing tobacco cessation treatment for Veterans in VA primary care and to have a thorough understanding of factors associated with implementation. Trial Registration:Clinicaltrials.govIdentifierNCT03477435.

Latent Heterogeneity in the Impact of Financial Coaching on Delay Discounting among Low-Income Smokers: A Secondary Analysis of a Randomized Controlled Trial

Low-income adults are significantly more likely to smoke, and face more difficulty in quitting, than people with high income. High rates of delay discounting (DD) may be an important factor contributing to the high rates of tobacco use among low-income adults. Future-oriented financial coaching may offer a novel approach in the treatment of smoking cessation among low-income adults. This secondary analysis (N = 251) of data from a randomized controlled trial examined the integration of future-oriented financial coaching into smoking cessation treatment for low-income smokers. Linear regression and finite mixture models (FMM) estimated the overall and the latent heterogeneity of the impact of the intervention versus usual care control on DD rates 6 months after randomization. Though standard linear regression found no overall difference in DD between intervention and control (β = −0.23, p = 0.338), the FMM identified two latent subgroups with different responses to the intervention. Subgroup 1 (79% of the sample) showed no difference in DD between intervention and control (β = 0.25, p = 0.08). Subgroup 2 (21% of the sample) showed significantly lower DD (β = −2.06, p = 0.003) among intervention group participants versus control at 6 months. Participants were more likely to be a member of subgroup 2 if they had lower baseline DD rates, were living at or below 100% of federal poverty, or were married/living with a partner. This study identified a group of low-income adults seeking to quit smoking who responded to financial coaching with decreased DD rates. These results can be used to inform future targeting of the intervention to individuals who may benefit most, as well as inform future treatment adaptations to support the subgroup of low-income smokers, who did not benefit.

A systematic review of mental health professionals, patients and carers' perceived barriers and enablers to supporting smoking cessation in mental health settings

Introduction

Evidence-based smoking cessation and temporary abstinence interventions to address smoking in mental health settings are available, but the impact of these interventions is limited.

Aims and Methods

We aimed to identify and synthesize the perceived barriers and enablers to supporting smoking cessation in mental health settings. Six databases were searched for articles reporting the investigation of perceived barriers and enablers to supporting smoking cessation in mental health settings. Data were extracted and coded using a mixed inductive/deductive method to the theoretical domains framework, key barriers and enablers were identified through the combining of coding frequency, elaboration, and expressed importance.

Results

Of 31 included articles, 56 barriers/enablers were reported from the perspectives of mental healthcare professionals (MHPs), 48 from patient perspectives, 21 from mixed perspectives, and 0 from relatives/carers. Barriers to supporting smoking cessation or temporary abstinence in mental health settings mainly fell within the domains: environmental context and resources (eg, MHPs lack of time); knowledge (eg, interactions around smoking that did occur were ill informed); social influences (eg, smoking norms within social network); and intentions (eg, MHPs lack positive intentions to deliver support). Enablers mainly fell within the domains: environmental context and resources (eg, use of appropriate support materials) and social influences (eg, pro-quitting social norms).

Conclusions

The importance of overcoming competing demands on staff time and resources, the inclusion of tailored, personalized support, the exploitation of patients wider social support networks, and enhancing knowledge and awareness around the benefits smoking cessation is highlighted.

Implications

Identified barriers and enablers represent targets for future interventions to improve the support of smoking cessation in mental health settings. Future research needs to examine the perceptions of the carers and family/friends of patients in relation to the smoking behavior change support delivered to patients.

Protocol: A multi-modal, physician-centered intervention to improve guideline-concordant prostate cancer imaging

BACKGROUND

Almost half of Veterans with localized prostate cancer receive inappropriate, wasteful staging imaging. Our team has explored the barriers and facilitators of guideline-concordant prostate cancer imaging and found that (1) patients with newly diagnosed prostate cancer have little concern for radiographic staging but rather focus on treatment and (2) physicians trust imaging guidelines but are apt to follow their own intuition, fear medico-legal consequences, and succumb to influence from imaging-avid colleagues. We used a theory-based approach to design a multi-level intervention strategy to promote guideline-concordant imaging to stage incident prostate cancer.

METHODS

We designed the Prostate Cancer Imaging Stewardship (PCIS) intervention: a multi-site, stepped wedge, cluster-randomized trial to determine the effect of a physician-focused behavioral intervention on Veterans Health Administration (VHA) prostate cancer imaging use. The multi-level intervention, developed according to the Theoretical Domains Framework (TDF) and Behavior Change Wheel, combines traditional physician behavior change methods with novel methods of communication and data collection. The intervention consists of three components: (1) a system of audit and feedback to clinicians informing individual clinicians and their sites about how their behavior compares to their peers' and to published guidelines, (2) a program of academic detailing with the goal to educate providers about prostate cancer imaging, and (3) a CPRS Clinical Order Check for potentially guideline-discordant imaging orders. The intervention will be introduced to 10 participating geographically distributed study sites.

DISCUSSION

This study is a significant contribution to implementation science, providing VHA an opportunity to ensure delivery of high-quality care at the lowest cost using a theory-based approach. The study is ongoing. Preliminary data collection and recruitment have started; analysis has yet to be performed.

TRIAL REGISTRATION

CliniclTrials.gov NCT03445559. Prospectively registered on February 26, 2018.

Effectiveness of Proactive Tobacco Cessation Treatment Outreach Among Smokers With Serious Mental Illness

INTRODUCTION

People with serious mental illness (SMI) have a high smoking prevalence and low quit rates. Few cessation treatments are tested in smokers with SMI. Mental health (MH) providers are reluctant to address smoking. Proactive tobacco cessation treatment strategies reach out directly to smokers to offer counseling and medication and improve treatment utilization and quit rates. The current study is a secondary analysis of a randomized controlled trial of proactive outreach for tobacco cessation treatment in VA MH patients.

AIMS AND METHODS

Participants (N = 1938, 83% male, mean age 55.7) across four recruitment sites, who were current smokers and had a MH visit in the past 12 months, were identified using the electronic medical record. Participants were randomized to Intervention (telephone outreach call plus invitation to engage in MH tailored telephone counseling and assistance obtaining nicotine replacement therapy) or Control (usual care). The current study assessed outcomes in participants with SMI (N = 982).

RESULTS

Compared to the Control group, participants assigned to the Intervention group were more likely to engage in telephone counseling (22% vs. 3%) and use nicotine replacement therapy (51% vs. 41%). Participants in the Intervention group were more likely to be abstinent (7-day point prevalence; 18%) at 12 months than participants in the Control group (11%) but equally likely to make quit attempts.

CONCLUSIONS

Proactive tobacco cessation treatment is an effective strategy for tobacco users with SMI. Proactive outreach had a particularly strong effect on counseling utilization. Future randomized clinical trials examining proactive tobacco treatment approaches in SMI treatment settings are needed.

IMPLICATIONS

Few effective treatment models exist for smokers with SMI. Proactive tobacco cessation outreach with connections to MH tailored telephone counseling and medication promotes tobacco abstinence among smokers with SMI and is an effective treatment strategy for this underserved population.

Proactive Tobacco Treatment in a Behavioral Health Home

Tobacco use is rarely addressed in community mental healthcare despite high patient smoking prevalence. Community mental health centers have systems in place that could be used to comprehensively address tobacco use. This study tested feasibility of, satisfaction with, and safety of proactive tobacco treatment (tobacco outreach to offer connection to tobacco cessation treatment). Behavioral health home patients who smoke were randomly assigned to usual care (UC; N = 11) or proactive care (PC; N = 9). All participants were called 3-months post-randomization for follow-up. PC patients reported high satisfaction with the program and experienced no adverse events or mental health symptom exacerbation during treatment. PC patients reported greater reductions in cigarettes per day, more quit attempts, and more cessation medication utilization than UC patients. Proactive outreach for tobacco cessation is feasible in a behavioral health home, acceptable to patients, and may reduce smoking heaviness and promote quit attempts.

Exploring the decoy effect to guide tobacco treatment choice: a randomized experiment

Objectives

Guidelines recommend that smokers participate in four or more counseling sessions when trying to quit, but smokers rarely engage in multiple sessions. The “decoy effect” is a cognitive bias that can cause consumer preferences for a “target” product to change when presented with a similar but inferior product (a “decoy”). This study tested the use of a decoy to guide smokers’ selection of a target number of counseling sessions. During an online survey, adult tobacco users (N = 93) were randomized to one of two groups that determined the answer choices they saw in response to a question assessing their interest in multi-session cessation counseling. Group A choose between two sessions or a “target” of five sessions. Group B was given a third “decoy” option of seven sessions. Binary logistic regression was used to compare groups on the proportion of participants selecting the “target.”

Results

Among 90 participants with complete data, a decoy effect was not found. There was no significant difference between groups in the proportion of participants selecting the target of five sessions (47% in Group B vs. 53% in Group A; aOR = 0.76, 95%CI 0.48–1.19).

Trial Registration This study was retrospectively registered at clinicaltrials.gov on December 13, 2019 (NCT04200157)

Motivational interviewing for smoking cessation

BACKGROUND

Motivational Interviewing (MI) is a directive patient-centred style of counselling, designed to help people to explore and resolve ambivalence about behaviour change. It was developed as a treatment for alcohol abuse, but may help people to a make a successful attempt to stop smoking.

OBJECTIVES

To evaluate the efficacy of MI for smoking cessation compared with no treatment, in addition to another form of smoking cessation treatment, and compared with other types of smoking cessation treatment. We also investigated whether more intensive MI is more effective than less intensive MI for smoking cessation.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register for studies using the term motivat* NEAR2 (interview* OR enhanc* OR session* OR counsel* OR practi* OR behav*) in the title or abstract, or motivation* as a keyword. We also searched trial registries to identify unpublished studies. Date of the most recent search: August 2018.

SELECTION CRITERIA

Randomised controlled trials in which MI or its variants were offered to smokers to assist smoking cessation. We excluded trials that did not assess cessation as an outcome, with follow-up less than six months, and with additional non-MI intervention components not matched between arms. We excluded trials in pregnant women as these are covered elsewhere.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methods. Smoking cessation was measured after at least six months, using the most rigorous definition available, on an intention-to-treat basis. We calculated risk ratios (RR) and 95% confidence intervals (CI) for smoking cessation for each study, where possible. We grouped eligible studies according to the type of comparison. We carried out meta-analyses where appropriate, using Mantel-Haenszel random-effects models. We extracted data on mental health outcomes and quality of life and summarised these narratively.

MAIN RESULTS

We identified 37 eligible studies involving over 15,000 participants who smoked tobacco. The majority of studies recruited participants with particular characteristics, often from groups of people who are less likely to seek support to stop smoking than the general population. Although a few studies recruited participants who intended to stop smoking soon or had no intentions to quit, most recruited a population without regard to their intention to quit. MI was conducted in one to 12 sessions, with the total duration of MI ranging from five to 315 minutes across studies. We judged four of the 37 studies to be at low risk of bias, and 11 to be at high risk, but restricting the analysis only to those studies at low or unclear risk did not significantly alter results, apart from in one case - our analysis comparing higher to lower intensity MI.We found low-certainty evidence, limited by risk of bias and imprecision, comparing the effect of MI to no treatment for smoking cessation (RR = 0.84, 95% CI 0.63 to 1.12; I² = 0%; adjusted N = 684). One study was excluded from this analysis as the participants recruited (incarcerated men) were not comparable to the other participants included in the analysis, resulting in substantial statistical heterogeneity when all studies were pooled (I² = 87%). Enhancing existing smoking cessation support with additional MI, compared with existing support alone, gave an RR of 1.07 (95% CI 0.85 to 1.36; adjusted N = 4167; I² = 47%), and MI compared with other forms of smoking cessation support gave an RR of 1.24 (95% CI 0.91 to 1.69; I² = 54%; N = 5192). We judged both of these estimates to be of low certainty due to heterogeneity and imprecision. Low-certainty evidence detected a benefit of higher intensity MI when compared with lower intensity MI (RR 1.23, 95% CI 1.11 to 1.37; adjusted N = 5620; I² = 0%). The evidence was limited because three of the five studies in this comparison were at risk of bias. Excluding them gave an RR of 1.00 (95% CI 0.65 to 1.54; I² = n/a; N = 482), changing the interpretation of the results.Mental health and quality of life outcomes were reported in only one study, providing little evidence on whether MI improves mental well-being.

AUTHORS' CONCLUSIONS

There is insufficient evidence to show whether or not MI helps people to stop smoking compared with no intervention, as an addition to other types of behavioural support for smoking cessation, or compared with other types of behavioural support for smoking cessation. It is also unclear whether more intensive MI is more effective than less intensive MI. All estimates of treatment effect were of low certainty because of concerns about bias in the trials, imprecision and inconsistency. Consequently, future trials are likely to change these conclusions. There is almost no evidence on whether MI for smoking cessation improves mental well-being.

Comparing Treatment Acceptability and 12-Month Cessation Rates in Response to Web-Based Smoking Interventions Among Smokers Who Do and Do Not Screen Positive for Affective Disorders: Secondary Analysis

BACKGROUND

Web-based cessation programs are now common for intervening with smokers. However, it remains unclear how acceptable or effective these interventions are among people with affective disorders and symptoms (ADS; eg, depression and anxiety). Research examining this is extremely limited, with mixed results on cessation rates. Additional large studies are needed to more fully understand whether Web-based interventions are similarly used and equally effective among people with and without affective disorder symptomology. If not, more targeted Web-based interventions may be required.

OBJECTIVE

The goal of the research was to compare Web-based treatment acceptability (defined by satisfaction and use) and 12-month cessation outcomes between smokers with and without ADS.

METHODS

Participants (N=2512) were adult smokers enrolled in a randomized, comparative effectiveness trial of two Web-based smoking interventions designed for the general population of smokers. At baseline, participants reported demographic and smoking characteristics and completed measures assessing ADS. Participants were then classified into subgroups based on their self-reported ADS-either into a no ADS group or into six nonmutually exclusive subgroups: depression, posttraumatic stress disorder (PTSD), panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), and more than one ADS. Surveys at 12 months postrandomization included subjective ratings of treatment acceptability and self-reported smoking cessation. Treatment use (ie, number of log-ins and total duration of exposure) was assessed via automated records.

RESULTS

Relative to the no ADS group, all six ADS subgroups reported significantly greater satisfaction with their assigned Web treatment program, but they spent less time logged in than those with no ADS. For number of log-ins, a treatment arm by ADS group interaction was observed across all ADS subgroups except GAD, suggesting that relative to the no ADS group, they logged in less to one website but not the other. At the 12-month follow-up, abstinence rates in the no ADS group (153/520, 29.42%) were significantly higher than for participants who screened positive for depression (306/1267, 24.15%; P=.03), PTSD (294/1215, 24.19%; P=.03), PD (229/1003, 23.83%; P=.009), and two or more ADS (323/1332, 24.25%; P=.03). Post hoc analyses suggest the lower quit rates may be associated with differences in baseline nicotine dependence and levels of commitment to resist smoking in difficult situations. Website use did not explain the differential abstinence rates.

CONCLUSIONS

Despite reporting higher levels of treatment satisfaction, most smokers with ADS used their assigned intervention less often and had lower quit rates than smokers with no ADS at treatment onset. The results support the need for developing more targeted interventions for smokers with ADS.

TRIAL REGISTRATION

Clinical Trials.gov NCT01812278; https://clinicaltrials.gov/ct2/show/NCT01812278 (Archived by WebCite at http://www.webcitation.org/78L9cNdG4).

Telephone counselling for smoking cessation

BACKGROUND

Telephone services can provide information and support for smokers. Counselling may be provided proactively or offered reactively to callers to smoking cessation helplines.

OBJECTIVES

To evaluate the effect of telephone support to help smokers quit, including proactive or reactive counselling, or the provision of other information to smokers calling a helpline.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, clinicaltrials.gov, and the ICTRP for studies of telephone counselling, using search terms including 'hotlines' or 'quitline' or 'helpline'. Date of the most recent search: May 2018.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials which offered proactive or reactive telephone counselling to smokers to assist smoking cessation.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We pooled studies using a random-effects model and assessed statistical heterogeneity amongst subgroups of clinically comparable studies using the I² statistic. In trials including smokers who did not call a quitline, we used meta-regression to investigate moderation of the effect of telephone counselling by the planned number of calls in the intervention, trial selection of participants that were motivated to quit, and the baseline support provided together with telephone counselling (either self-help only, brief face-to-face intervention, pharmacotherapy, or financial incentives).

MAIN RESULTS

We identified 104 trials including 111,653 participants that met the inclusion criteria. Participants were mostly adult smokers from the general population, but some studies included teenagers, pregnant women, and people with long-term or mental health conditions. Most trials (58.7%) were at high risk of bias, while 30.8% were at unclear risk, and only 11.5% were at low risk of bias for all domains assessed. Most studies (100/104) assessed proactive telephone counselling, as opposed to reactive forms.Among trials including smokers who contacted helplines (32,484 participants), quit rates were higher for smokers receiving multiple sessions of proactive counselling (risk ratio (RR) 1.38, 95% confidence interval (CI) 1.19 to 1.61; 14 trials, 32,484 participants; I² = 72%) compared with a control condition providing self-help materials or brief counselling in a single call. Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate.In studies that recruited smokers who did not call a helpline, the provision of telephone counselling increased quit rates (RR 1.25, 95% CI 1.15 to 1.35; 65 trials, 41,233 participants; I² = 52%). Due to the substantial unexplained heterogeneity between studies, we downgraded the certainty of the evidence to moderate. In subgroup analysis, we found no evidence that the effect of telephone counselling depended upon whether or not other interventions were provided (P = 0.21), no evidence that more intensive support was more effective than less intensive (P = 0.43), or that the effect of telephone support depended upon whether or not people were actively trying to quit smoking (P = 0.32). However, in meta-regression, telephone counselling was associated with greater effectiveness when provided as an adjunct to self-help written support (P < 0.01), or to a brief intervention from a health professional (P = 0.02); telephone counselling was less effective when provided as an adjunct to more intensive counselling. Further, telephone support was more effective for people who were motivated to try to quit smoking (P = 0.02). The findings from three additional trials of smokers who had not proactively called a helpline but were offered telephone counselling, found quit rates were higher in those offered three to five telephone calls compared to those offered just one call (RR 1.27, 95% CI 1.12 to 1.44; 2602 participants; I² = 0%).

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that proactive telephone counselling aids smokers who seek help from quitlines, and moderate-certainty evidence that proactive telephone counselling increases quit rates in smokers in other settings. There is currently insufficient evidence to assess potential variations in effect from differences in the number of contacts, type or timing of telephone counselling, or when telephone counselling is provided as an adjunct to other smoking cessation therapies. Evidence was inconclusive on the effect of reactive telephone counselling, due to a limited number studies, which reflects the difficulty of studying this intervention.

Review of the role of cigarette smoking in diabetic foot

Diabetic foot ulceration has been a serious issue over the past decades in Asia, causing economic and social problems. Therefore, it is important to identify and reduce the risk factors of diabetic foot. Cigarette smoking has been reported to be associated with diabetes and its macrovascular complications, but the relationship between smoking and diabetic foot ulcers is still unclear. In the present review, we summarize the effects of cigarette smoking on diabetic foot ulcers with respect to peripheral neuropathy, vascular alterations and wound healing. One underlying mechanism of these impacts might be the smoking-induced oxidative stress inside the cells. At the end of this review, the current mainstream therapies for smoking cessation are also outlined. We believe that it is urgent for all diabetic patients to quit smoking so as to reduce their chances of developing foot ulcers and to improve the prognosis of diabetic foot ulcers.

Effectiveness of a telephone-based intervention for smoking cessation in patients with severe mental disorders: study protocol for a randomized controlled trial

Background

Up to 75% of inpatients with mental disorders smoke, and their life expectancy is decreased by up to 25 years compared to the general population. Hospitalized patients without monitoring after discharge quickly return to prehospitalization levels of tobacco use. The aim of the 061 QuitMental study is to assess the effectiveness of a multicomponent and motivational telephone-based intervention to stop smoking through a quitline addressed to smokers discharged from mental health hospital wards.

Methods

A pragmatic randomized controlled trial, single blinded, will include 2:1 allocation to the intervention group (IG) and the control group (CG). The IG will receive telephone assistance to quit smoking (including psychological and psychoeducational support, and pharmacological treatment advice if required) proactively for 12 months, and the CG will receive only brief advice after discharge. The sample size, calculated with an expected difference of 15 points on smoking abstinence between groups (IG, 20% and CG, 5%), α = 0.05, β = 0.10, and 20% loss, will be 334 participants (IG) and 176 participants (CG). Participants are adult smokers discharged from psychiatric units of five acute hospitals.

Measurements include dependent variables (self-reported 7-day point prevalence smoking abstinence (carbon monoxide verified), duration of abstinence, number of quit attempts, motivation, and self-efficacy to quit) and independent variables (age, sex, and psychiatric diagnoses). In data analysis, IG and CG data will be compared at 48 h and 1, 6, and 12 months post discharge. Multivariate logistic regression (odds ratio; 95% confidence interval) of dependent variables adjusted for potential confounding variables will be performed. The number needed to treat to achieve one abstinence outcome will be calculated. We will compare the abstinence rate of enrolled patients between groups.

Discussion

This trial evaluates an innovative format of a quitline for smokers with severe mental disorders regardless of their motivation to quit. If effective, the pragmatic nature of the study will permit transfer to routine clinical practice in the National Health System.

Trial registration

ClinicalTrials.gov, NCT03230955. Registered on 24 July 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3106-5) contains supplementary material, which is available to authorized users.

Proactive Tobacco Treatment for Smokers Using Veterans Administration Mental Health Clinics

INTRODUCTION

Veterans with a mental health diagnosis have high rates of tobacco use but encounter low rates of treatment from providers. This study tested whether a proactive tobacco treatment approach increases treatment engagement and abstinence rates in Department of Veterans Affairs mental health patients.

STUDY DESIGN

RCT.

SETTING/PARTICIPANTS

The study was performed from 2013 to 2017 and analyses were conducted in 2017. Investigators used the electronic medical record at four Veterans Administration facilities to identify patients documented as current smokers and who had a mental health clinic visit in the past 12 months.

INTERVENTION

Patients were mailed an introductory letter and baseline survey. Survey respondents were enrolled and randomized to intervention (n=969) or control (n=969). Control participants received a list of usual Veterans Administration smoking services. Intervention participants received a motivational outreach call, multisession telephone counseling, and assistance with obtaining nicotine replacement therapy.

MAIN OUTCOME MEASURES

Participants completed surveys at baseline, 6 months, and 12 months after randomization. The primary outcome was self-reported 7-day abstinence from cigarettes at 12-month follow-up. Secondary outcomes included use of cessation treatment, self-reported 7-day abstinence at 6-month follow-up, and 6-month prolonged abstinence at 12-month follow-up.

RESULTS

At 12 months, intervention participants were more likely to report using telephone counseling (19% vs 3%, OR=7.34, 95% CI=4.59, 11.74), nicotine replacement therapy (47% vs 35%, OR=1.63, 95% CI=1.31, 2.03), or both counseling and nicotine replacement therapy (16% vs 2%, OR=11.93, 95% CI=6.34, 22.47). Intervention participants were more likely to report 7-day abstinence (19% vs 14%, OR=1.50, 95% CI=1.12, 2.01) and prolonged 6-month abstinence (16% vs 9%, OR=1.87, 95% CI=1.34, 2.61). After adjusting for non-ignorable missingness at follow-up, the intervention effects on 7-day and prolonged abstinence remained significant (p<0.05).

CONCLUSIONS

Proactive outreach was more effective than usual Veterans Administration care at increasing treatment engagement and long-term abstinence in mental health patients.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01737281.

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.

Proactive tobacco treatment for individuals with and without a mental health diagnosis: Secondary analysis of a pragmatic randomized controlled trial

INTRODUCTION

Individuals with (vs. without) mental illness use tobacco at higher rates and have more difficulty quitting. Treatment models for smokers with mental illness are needed.

METHODS

This secondary analysis of the Victory Over Tobacco study [a pragmatic randomized clinical trial (N=5123) conducted in 2009-2011 of Proactive Care (proactive outreach plus connection to smoking cessation services) vs. Usual Care] tests the effectiveness of treatment assignment in participants with and without a mental health diagnosis on population-level, 6month prolonged abstinence at one year follow-up.

RESULTS

Analyses conducted in 2015-6 found that there was no interaction between treatment group and mental health group on abstinence (F(1,3300=1.12, p=0.29)). Analyses stratified by mental health group showed that those without mental illness, assigned to Proactive Care, had a significantly higher population-level abstinence rate than those assigned to Usual Care (OR=1.40, 95% CI=1.17-1.67); in those with mental illness, assignment to Proactive Care produced a non-significant increase in abstinence compared to Usual Care (OR=1.18, 95% CI=0.98-1.41). Those with mental illness reported more medical visits, cessation advice and treatment (p<0.001), similar levels of abstinence motivation (p>0.05), but lower abstinence self-efficacy (p<0.001).

CONCLUSIONS

Those with a mental health diagnosis benefitted less from proactive outreach regarding tobacco use. VA primary care patients with mental illness may not need additional outreach because they are connected to cessation resources during medical appointments. This group may also require more intensive cessation interventions targeting self-efficacy to improve cessation rates. Clinicaltrials.gov registration # NCT00608426.

Innovative approaches to support smoking cessation for individuals with mental illness and co-occurring substance use disorders

INTRODUCTION

Tobacco remains the leading preventable cause of death in the US, accounting for over 520,000 deaths annually. While the smoking prevalence has declined over the past 50 years, those with mental illness and addictive disorders continue to smoke at high levels and with significant tobacco-related health problems. Areas covered: This review highlights the epidemiology, contributing factors, and evidence-base for intervening upon tobacco use in those with mental illness and addictive disorders. Historically underprioritized, a growing body of literature supports treating tobacco within mental health and addiction treatment settings. Critically, treating tobacco use appears to support, and not harm, mental health recovery and sobriety. This review also summarizes novel, emerging approaches to mitigate the harms of cigarette smoking. Expert commentary: People with mental illness and addictive disorders have a high prevalence of tobacco use with serious health harms. Treating tobacco use is essential. Evidence-based strategies include individual treatments that are stage-matched to readiness to quit and combine cessation medications with behavioral therapies, supported by smoke-free policies in treatment settings and residential environments. Emerging approaches, with a focus on harm reduction, are electronic nicotine delivery systems and tobacco regulatory efforts to reduce the nicotine content in cigarettes, thereby reducing their addiction potential.

A systematic narrative review of the effectiveness of behavioural smoking cessation interventions in selected disadvantaged groups (2010-2017)

INTRODUCTION

Tobacco remains the key modifiable risk factor for the development of a number of diseases, including cardiovascular disease, cerebrovascular disease, lower respiratory infections, chronic obstructive pulmonary disease, tuberculosis and cancer. Among priority populations, smoking prevalence remains high, smokers tend to relapse more often and earlier and fewer are able to sustain quit attempts. This systematic review provides an update on the literature. Areas covered: Twenty-four randomized controlled trials published from 2010-2017, in English language, were identified after searching on Medline, Ovid, Embase and PsycINFO databases. Studies reported on the effectiveness of smoking cessation interventions among six disadvantaged groups known to have high smoking rates: (i) homeless, (ii) prisoners, (iii) indigenous populations, (iv) at-risk youth, (v) people with low income, and (vi) those with a mental illness. Narrative review and assessment of methodological quality of included papers was undertaken. Expert commentary: There is a growing evidence base of methodologically robust studies evaluating a variety of behavioural smoking cessation interventions for priority populations. Multi-component interventions and those examining behavioural interventions incorporating mindfulness training, financial incentives, motivational interviewing and extended telephone-delivered counseling may be effective in the short-term, particularly for smokers on low incomes and people with a mental illness.

Long-term abstinence and predictors of tobacco treatment uptake among hospitalized smokers with serious mental illness enrolled in a smoking cessation trial

Hospital patients with serious mental illness (SMI) have high rates of smoking. There are few post-discharge treatment models available for this population and limited research on their treatment uptake following discharge. This study is a secondary analysis of an RCT that compared multi-session intensive telephone counseling versus referral to state quitline counseling at two safety net hospitals in New York City. For this analysis, we selected all trial participants with a history of schizophrenia, schizoaffective disorder or bipolar disorder (N = 384) and used multivariable logistic regression to compare groups on self-reported 30-day abstinence at 6 months and to identify patient factors associated with use of tobacco treatment. Analyses found no significant group differences in abstinence 6 months (28% quitline vs. 29% intervention, p > 0.05), use of cessation medications (42% quitline vs. 47% intervention, p > 0.05) or receipt of at least one counseling call (47% quitline vs. 42% intervention, p > 0.05). Patients with hazardous drinking (p = 0.04) or perceived good health (p = 0.03) were less likely to use cessation medications. Homeless patients were less likely to use counseling (p = 0.02). Most patients did not use cessation treatment after discharge, and the intensive intervention did not improve abstinence rates over quitline referral. Interventions are needed to improve use of cessation treatment and long-term abstinence in patients with SMI.

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-Cessation Interventions for Urban Hospital Patients: A Randomized Comparative Effectiveness Trial

INTRODUCTION

Hospitalization is a unique opportunity for smoking cessation, but prior interventions have measured efficacy with narrowly defined populations. The objective of this study was to enroll smokers admitted to two "safety net" hospitals and compare the effectiveness of two post-discharge cessation interventions.

DESIGN

A randomized comparative effectiveness trial was conducted.

SETTING/PARTICIPANTS

At two New York City public hospitals, every hospitalized patient identified as a smoker (based on admission records) was approached. Inclusion criteria were: smoked cigarettes in the past 30 days; spoke English, Spanish, or Mandarin; had a U.S. phone number; not discharged to an institution where follow-up or smoking was limited; and not pregnant/breastfeeding. Of 18,797 patients identified as current smokers between July 2011 and April 2014, a total of 3,047 (16%) were discharged before being approached, 3,273 (17%) were not current smokers, 4,026 (21%) had no U.S. phone number, 2,831 (15%) were ineligible for other reasons, and 3,983 (21%) refused participation. In total, 1,618 (9%) participants enrolled in the study. During follow-up, 69% of participants were reached at 2 months and 68% at 6 months.

INTERVENTION

At discharge, participants were randomized to multisession telephone counseling from study staff (n=804) or referral to the state quitline for proactive outreach and counseling (n=814).

MAIN OUTCOME MEASURES

Self-reported abstinence at 6 months was measured. Analyses were conducted in late 2015.

RESULTS

One quarter of participants were homeless or in unstable housing, 60% had a history of substance abuse, 43% reported current hazardous drinking, and half had a psychiatric diagnosis other than substance abuse. At follow-up, the rate of abstinence (30-day point prevalence) was higher in the intensive counseling arm than the quitline arm at 2 months (29.0% vs 20.7%; relative risk=1.40; 95% CI=1.13, 1.73) and 6 months (37.4% vs 31.5%; relative risk=1.19; 95% CI=1.01, 1.40).

CONCLUSIONS

Intensive counseling was more effective than referral to the state quitline. Long-term abstinence was excellent in both groups. Many patients were not eligible for enrollment despite minimal exclusion criteria.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT01363245.

Relationship between tobacco cessation and mental health outcomes in a tobacco cessation trial

Persons with mental health diagnoses use tobacco at alarming rates, yet misperceptions remain about the effect of quitting on mental health outcomes. This article examines the relationship between tobacco cessation and changes in severity of mental illness. Participants were N = 577 veterans with a history of mental health treatment enrolled in a tobacco cessation study. The effects of abstinence and time on Behavior and Symptom Identification Scale-24 summary scores and subscales were examined. Abstinence at both 2 and 6 months post-baseline was related ( p < .0001) to lower Behavior and Symptom Identification Scale-24 summary scores and improvement on three Behavior and Symptom Identification Scale-24 subscales. Providers should recommend and provide tobacco treatment to all mental health patients to improve their physical and mental health functioning.