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Brown RA, Minami H, Hecht J, Kahler CW, Price LH, Kjome KL, Bloom EL, Levy DE, Carpenter KM, Smith A, Smits JAJ, Rigotti NA. Sustained Care Smoking Cessation Intervention for Individuals Hospitalized for Psychiatric Disorders: The Helping HAND 3 Randomized Clinical Trial. JAMA Psychiatry 2021; 78:839-847. [PMID: 33950156 PMCID: PMC8100915 DOI: 10.1001/jamapsychiatry.2021.0707] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
IMPORTANCE Smoking among individuals with serious mental illness (SMI) represents a major public health problem. Intervening during a psychiatric hospital stay may provide an opportunity to aid engagement in smoking cessation treatment and facilitate success in quitting. OBJECTIVE To examine the effectiveness of a multicomponent, sustained care (SusC) smoking cessation intervention in adults with SMI receiving inpatient psychiatric care. DESIGN, SETTING, AND PARTICIPANTS The Helping HAND 3 randomized clinical trial compared SusC with usual care (UC) among individuals with SMI who smoked daily and were receiving inpatient psychiatric care in Austin, Texas, in a single hospital. The study was conducted from July 2015 through August 2019. INTERVENTIONS The UC intervention involved brief smoking cessation information, self-help materials and advice from the admitting nurse, and an offer to provide nicotine replacement therapy during hospitalization. The SusC intervention included 4 main components designed to facilitate patient engagement with postdischarge smoking cessation resources: (1) inpatient motivational counseling; (2) free transdermal nicotine patches on discharge; (3) an offer of free postdischarge telephone quitline, text-based, and/or web-based smoking cessation counseling, and (4) postdischarge automated interactive voice response calls or text messages. MAIN OUTCOMES AND MEASURES The primary outcome was biochemically verified 7-day point-prevalence abstinence at 6-month follow-up. A secondary outcome was self-reported smoking cessation treatment use at 1, 3, and 6 months after discharge. RESULTS A total of 353 participants were randomized, of whom 342 were included in analyses (mean [SD] age, 35.8 [12.3] years; 268 White individuals [78.4%]; 280 non-Hispanic individuals [81.9%]; 169 women [49.4%]). They reported smoking a mean (SD) of 16.9 (10.4) cigarettes per day. Participants in the SusC group evidenced significantly higher 6-month follow-up point-prevalence abstinence rates than those in the UC group (8.9% vs 3.5%; adjusted odds ratio, 2.95 [95% CI, 1.24-6.99]; P = .01). The number needed to treat was 18.5 (95% CI, 9.6-306.4). A series of sensitivity analyses confirmed effectiveness. Finally, participants in the SusC group were significantly more likely to report using smoking cessation treatment over the 6 months postdischarge compared with participants in the UC group (74.6% vs 40.5%; relative risk, 1.8 [95% CI, 1.51-2.25]; P < .001). CONCLUSIONS AND RELEVANCE The findings of this randomized clinical trial provide evidence for the effectiveness of a scalable, multicomponent intervention in promoting smoking cessation treatment use and smoking abstinence in individuals with SMI following hospital discharge. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02204956.
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Affiliation(s)
| | - Haruka Minami
- Department of Psychology, Fordham University, Bronx, New York
| | - Jacki Hecht
- School of Nursing, University of Texas at Austin, Austin
| | - Christopher W. Kahler
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, Rhode Island,Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island
| | - Lawrence H. Price
- Butler Hospital, Alpert Medical School of Brown University, Providence, Rhode Island,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Kimberly L. Kjome
- Seton Shoal Creek Hospital, Austin, Texas,Department of Psychiatry, Dell Medical School at the University of Texas at Austin, Austin
| | - Erika Litvin Bloom
- Rhode Island Hospital, Providence, Rhode Island,Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island,Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Douglas E. Levy
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Harvard Medical School, Boston,Mongan Institute Health Policy Research Center, Department of Medicine, Massachusetts Medical School, Harvard Medical School, Boston
| | | | - Ashleigh Smith
- Department of Psychiatry, Dell Medical School, University of Texas at Austin, Austin,Department of Health Social Work, Steve Hicks School of Social Work, University of Texas at Austin, Austin
| | | | - Nancy A. Rigotti
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Harvard Medical School, Boston
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Morris CD, Lukowski AV, Vargas-Belcher RA, Ylioja TE, Nash CM, Bailey LA. Quitline Programs Tailored for Mental Health: Initial Outcomes and Feasibility. Am J Prev Med 2021; 60:S163-S171. [PMID: 33663704 DOI: 10.1016/j.amepre.2020.02.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 01/23/2020] [Accepted: 02/04/2020] [Indexed: 01/25/2023]
Abstract
INTRODUCTION The general efficacy of quitlines has been widely demonstrated, but uncertainty exists regarding how quitlines might best intervene for persons with mental health conditions. A total of 1 in 5 people in the U.S. has a diagnosable psychiatric disorder. These individuals smoke at 2‒4 times the rate of smoking among those without a mental health condition and face high rates of related death and disability. About half of quitline callers self-report a mental health condition, but until recently, quitline protocols tailored to these smokers did not exist. METHODS This paper provides initial results for tailored mental health programs from the largest quitline providers in the U.S., Optum and National Jewish Health. From 2017 to 2018, cohorts of callers with a mental health condition who enrolled in tailored programs were compared with cohorts with a mental health condition who received standard care. Both mental health programs offered participants additional calls, longer duration of combination nicotine-replacement therapy, and attention to mental health issues. Analyses were conducted in 2018-2019. RESULTS Findings suggest that callers with a mental health condition benefit from both standard care and tailored mental health services. Tailored programming did well in engaging people with mental health conditions. At the same time, there were no significant differences in abstinence rates when comparing mental health programs with standard care. Mental health cohorts did receive significantly greater service durations, more counseling calls, and longer nicotine-replacement therapy duration. CONCLUSIONS Tailored mental health quitline programs present a promising framework for testing the services that address psychiatric symptoms as well as other frequent population characteristics such as chronic illness. Implications for increasing reach to the often underserved population with a mental health condition are discussed.
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Affiliation(s)
- Chad D Morris
- Department of Psychiatry, University of Colorado, Aurora, Colorado.
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Stead LF, Koilpillai P, Fanshawe TR, Lancaster T. Combined pharmacotherapy and behavioural interventions for smoking cessation. Cochrane Database Syst Rev 2016; 3:CD008286. [PMID: 27009521 PMCID: PMC10042551 DOI: 10.1002/14651858.cd008286.pub3] [Citation(s) in RCA: 231] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Both behavioural support (including brief advice and counselling) and pharmacotherapies (including nicotine replacement therapy (NRT), varenicline and bupropion) are effective in helping people to stop smoking. Combining both treatment approaches is recommended where possible, but the size of the treatment effect with different combinations and in different settings and populations is unclear. OBJECTIVES To assess the effect of combining behavioural support and medication to aid smoking cessation, compared to a minimal intervention or usual care, and to identify whether there are different effects depending on characteristics of the treatment setting, intervention, population treated, or take-up of treatment. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group Specialised Register in July 2015 for records with any mention of pharmacotherapy, including any type of NRT, bupropion, nortriptyline or varenicline. SELECTION CRITERIA Randomized or quasi-randomized controlled trials evaluating combinations of pharmacotherapy and behavioural support for smoking cessation, compared to a control receiving usual care or brief advice or less intensive behavioural support. We excluded trials recruiting only pregnant women, trials recruiting only adolescents, and trials with less than six months follow-up. DATA COLLECTION AND ANALYSIS Search results were prescreened by one author and inclusion or exclusion of potentially relevant trials was agreed by two authors. Data was extracted by one author and checked by another.The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model. MAIN RESULTS Fifty-three studies with a total of more than 25,000 participants met the inclusion criteria. A large proportion of studies recruited people in healthcare settings or with specific health needs. Most studies provided NRT. Behavioural support was typically provided by specialists in cessation counselling, who offered between four and eight contact sessions. The planned maximum duration of contact was typically more than 30 minutes but less than 300 minutes. Overall, studies were at low or unclear risk of bias, and findings were not sensitive to the exclusion of any of the six studies rated at high risk of bias in one domain. One large study (the Lung Health Study) contributed heterogeneity due to a substantially larger treatment effect than seen in other studies (RR 3.88, 95% CI 3.35 to 4.50). Since this study used a particularly intensive intervention which included extended availability of nicotine gum, multiple group sessions and long term maintenance and recycling contacts, the results may not be comparable with the interventions used in other studies, and hence it was not pooled in other analyses. Based on the remaining 52 studies (19,488 participants) there was high quality evidence (using GRADE) for a benefit of combined pharmacotherapy and behavioural treatment compared to usual care, brief advice or less intensive behavioural support (RR 1.83, 95% CI 1.68 to 1.98) with moderate statistical heterogeneity (I² = 36%).The pooled estimate for 43 trials that recruited participants in healthcare settings (RR 1.97, 95% CI 1.79 to 2.18) was higher than for eight trials with community-based recruitment (RR 1.53, 95% CI 1.33 to 1.76). Compared to the first version of the review, previous weak evidence of differences in other subgroup analyses has disappeared. We did not detect differences between subgroups defined by motivation to quit, treatment provider, number or duration of support sessions, or take-up of treatment. AUTHORS' CONCLUSIONS Interventions that combine pharmacotherapy and behavioural support increase smoking cessation success compared to a minimal intervention or usual care. Updating this review with an additional 12 studies (5,000 participants) did not materially change the effect estimate. Although trials differed in the details of their populations and interventions, we did not detect any factors that modified treatment effects apart from the recruitment setting. We did not find evidence from indirect comparisons that offering more intensive behavioural support was associated with larger treatment effects.
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Affiliation(s)
- Lindsay F Stead
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterWoodstock RoadOxfordUKOX2 6GG
| | | | - Thomas R Fanshawe
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterWoodstock RoadOxfordUKOX2 6GG
| | - Tim Lancaster
- University of OxfordNuffield Department of Primary Care Health SciencesRadcliffe Observatory QuarterWoodstock RoadOxfordUKOX2 6GG
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Gaalema DE, Miller ME, Tidey JW. Predicted Impact of Nicotine Reduction on Smokers with Affective Disorders. TOB REGUL SCI 2015; 1:154-165. [PMID: 26236765 PMCID: PMC4517852 DOI: 10.18001/trs.1.2.5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES In 2009 the FDA acquired the authority to reduce the nicotine content in cigarettes if appropriate for public health, prompting research to evaluate the implications of this policy scientifically. Studies in non-psychiatric populations show that reducing the nicotine content of cigarettes to non-addictive levels reduces smoking rates and nicotine dependence. However, few studies have examined this hypothesis in vulnerable populations. METHODS In this narrative review we examined the extant literature on the effects of nicotine reduction or cessation on symptoms of withdrawal, as well as psychiatric symptoms, among those with affective disorders. RESULTS Following initial withdrawal from nicotine, smokers with affective disorders experience more severe mood disruption than smokers without these disorders. Use of very low nicotine content (VLNC) cigarettes during abstinence may help mitigate the mood-disrupting effects of initial abstinence. Once the initial effects of nicotine withdrawal on mood have passed, longer-term abstinence is associated with psychiatric improvement rather than worsening. CONCLUSIONS These findings suggest that if a national nicotine reduction policy were to be implemented, smokers with affective disorders would need additional support to overcome initial withdrawal but that long-term outcomes would likely be positive.
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Affiliation(s)
- Diann E Gaalema
- Vermont Center of Behavior and Health, University of Vermont, Burlington VT
| | - Mollie E Miller
- Center for Alcohol and Addictions Studies, Brown University, Providence RI
| | - Jennifer W Tidey
- Center for Alcohol and Addictions Studies, Brown University, Providence RI
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Audrain-McGovern J, Leventhal AM, Strong DR. The Role of Depression in the Uptake and Maintenance of Cigarette Smoking. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2015; 124:209-43. [PMID: 26472531 PMCID: PMC7518154 DOI: 10.1016/bs.irn.2015.07.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Cigarette smoking and depression both account for significant morbidity, mortality, and economic burden. The prevalence of both smoking and depression increase across mid-to-late adolescence and show high rates of comorbidity. While little is known about why smoking is disproportionately higher among depressed adolescents than adolescents without depression, emerging research has begun to offer some initial insights. The high rates of comorbidity between depression and smoking emphasize the importance of identifying intervention targets to inform smoking prevention efforts for this high-risk group. Interventions during adolescence may lessen the prevalence of depression-prone adult smokers. Depression is over-represented among adult smokers and contributes to lower smoking cessation rates. Negative mood management and pharmacotherapy have been the central focus of smoking cessation interventions for depression-prone populations to date. Converging lines of research highlight novel smoking cessation targets such as the maintenance of positive mood and reward regulation. Smoking cessation research in depression-prone smokers is critical to identify efficacious treatments that will ultimately decrease the excess smoking burden for this population.
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Affiliation(s)
- Janet Audrain-McGovern
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Adam M Leventhal
- Departments of Preventive Medicine and Psychology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - David R Strong
- Department of Family Medicine and Public Health, University of California, San Diego, California, USA
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6
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Schuck RK, Dahl A, Hall SM, Delucchi K, Fromont SC, Hall SE, Bonas T, Prochaska JJ. Smokers with serious mental illness and requests for nicotine replacement therapy post-hospitalisation. Tob Control 2014; 25:27-32. [PMID: 25209524 DOI: 10.1136/tobaccocontrol-2014-051712] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 08/22/2014] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND AIMS Smoke-free psychiatric hospitalisation provides opportunity for initiating tobacco cessation treatment. The current study reports on psychiatric patients' interest in continuing nicotine replacement therapy (NRT) posthospitalisation and examines patient predictors of NRT requests, quit attempts and abstinence at 1-week follow-up. METHODS Daily smokers were recruited and interviewed on locked psychiatric units at three smoke-free San Francisco Bay Area hospitals. Intent to quit smoking was not required to participate and 73% of eligible smokers enrolled. Analyses focused on 816 participants (49% female) randomised to interventions providing counselling tailored to readiness to quit with availability of NRT posthospitalisation. Logistic regressions tested demographic, smoking and psychiatric factors predictive of NRT requests, quit attempts and abstinence 1-week postdischarge. RESULTS Participants averaged 17 (SD=10) cigarettes/day for an average of 19 (SD=14) years. Most (88%) requested study-provided NRT (74% right at discharge). Participants preparing to quit and those with more severe psychiatric symptoms were more likely to request NRT at discharge (p<0.01). Those with more severe psychiatric symptoms also were more likely to request NRT refill, as were older participants (p<0.05). Participants who requested NRT at discharge were more likely to make a 24 h quit attempt and self-report abstinence at the 1-week follow-up (54% quit attempt, 14% abstinent) than participants who did not (25% quit attempt, 4% abstinent) (p<0.05). CONCLUSIONS The great demand for NRT and the association between NRT use with quit attempts and abstinence at 1-week posthospitalisation supports adoption of tobacco treatment in acute psychiatric settings. TRIAL REGISTRATION NUMBER # NCT00968513.
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Affiliation(s)
- Rachel K Schuck
- Department of Medicine, Stanford Prevention Research Center, Stanford University, Stanford, California, USA
| | - Audun Dahl
- Department of Psychology, University of California, Santa Cruz, Santa Cruz, California, USA
| | - Sharon M Hall
- Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA
| | - Kevin Delucchi
- Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA
| | - Sebastien C Fromont
- Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA
| | - Stephen E Hall
- Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA
| | - Thomas Bonas
- Alta Bates Summit Medical Center, Herrick Hospital, Berkeley, California, USA
| | - Judith J Prochaska
- Department of Medicine, Stanford Prevention Research Center, Stanford University, Stanford, California, USA Department of Psychiatry, University of California, San Francisco, San Francisco, California, USA
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Abstract
BACKGROUND A high proportion of smokers suffer from mental health problems including depression. Despite many of them wanting to stop smoking, low mood adversely affects their ability to quit. OBJECTIVE To explore the experiences of smokers with self-reported depression, the relationship of smoking with mental health problems and the experiences of smokers while trying to quit. The study also explored what help within the primary care setting could assist in quitting. METHODS Participants were recruited from a large general-practice-based smoking cessation trial. Participants who had indicated they were suffering from depression on a self-reported baseline survey were invited to participate. Semi-structured interviews were conducted over the telephone and digitally recorded. The interviews were transcribed and analysed using a phenomenological qualitative approach. RESULTS Sixteen interviews were conducted (11 females, 5 males). Mood disturbances were frequently reported as triggers for smoking and low mood was seen as a barrier to quitting. Perceived benefits of smoking when depressed were limited and for many, it was a learned response. A sense of hopelessness, lack of control over one's life and a lack of meaningful activities all emerged as important factors contributing to continued smoking. Participants felt that their quit attempts would be aided by better mood management, increased self-confidence and motivation and additional professional support. CONCLUSIONS Smoking and depression were found to be strongly interconnected. Depressed smokers interested in quitting may benefit from increased psychological help to enhance self-confidence, motivation and mood management, as well as a supportive general practice environment.
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Affiliation(s)
- Nicole Clancy
- School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
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8
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Abstract
BACKGROUND Both behavioural support (including brief advice and counselling) and pharmacotherapies (including nicotine replacement therapy (NRT), varenicline and bupropion) are effective in helping people to stop smoking. Combining both treatment approaches is recommended where possible, but the size of the treatment effect with different combinations and in different settings and populations is unclear. OBJECTIVES To assess the effect of combining behavioural support and medication to aid smoking cessation, compared to a minimal intervention or usual care, and to identify whether there are different effects depending on characteristics of the treatment setting, intervention, population treated, or take-up of treatment. SEARCH METHODS We searched the Cochrane Tobacco Addiction Group Specialised Register in July 2012 for records with any mention of pharmacotherapy, including any type of NRT, bupropion, nortriptyline or varenicline. SELECTION CRITERIA Randomized or quasi-randomized controlled trials evaluating combinations of pharmacotherapy and behavioural support for smoking cessation, compared to a control receiving usual care or brief advice or less intensive behavioural support. We excluded trials recruiting only pregnant women, trials recruiting only adolescents, and trials with less than six months follow-up. DATA COLLECTION AND ANALYSIS Search results were prescreened by one author and inclusion or exclusion of potentially relevant trials was agreed by both authors. Data was extracted by one author and checked by the other.The main outcome measure was abstinence from smoking after at least six months of follow-up. We used the most rigorous definition of abstinence for each trial, and biochemically validated rates if available. We calculated the risk ratio (RR) and 95% confidence interval (CI) for each study. Where appropriate, we performed meta-analysis using a Mantel-Haenszel fixed-effect model. MAIN RESULTS Forty-one studies with a total of more than 20,000 participants met the inclusion criteria. A large proportion of studies recruited people in healthcare settings or with specific health needs. Most studies provided NRT. Behavioural support was typically provided by specialists in cessation counselling, who offered between four and eight contact sessions. The planned maximum duration of contact was typically more than 30 minutes but less than 300 minutes. Overall, studies were at low or unclear risk of bias, and findings were not sensitive to the exclusion of any of the three studies rated at high risk of bias in one domain. One large study (the Lung Health Study) contributed heterogeneity due to a substantially larger treatment effect than seen in other studies (RR 3.88, 95% CI 3.35 to 4.50). Since this study used a particularly intensive intervention which included extended availability of nicotine gum, multiple group sessions and long term maintenance and recycling contacts, the results may not be comparable with the interventions used in other studies, and hence it was not pooled in other analyses. Based on the remaining 40 studies (15,021 participants) there was good evidence for a benefit of combination pharmacotherapy and behavioural treatment compared to usual care or brief advice or less intensive behavioural support (RR 1.82, 95% CI 1.66 to 2.00) with moderate statistical heterogeneity (I² = 40%). The pooled estimate for 31 trials that recruited participants in healthcare settings (RR 2.06, 95% CI 1.81 to 2.34) was higher than for eight trials with community-based recruitment (RR 1.53, 95% CI 1.33 to 1.76). Pooled estimates were lower in a subgroup of trials where the behavioural intervention was provided by specialist counsellors versus trials where counselling was linked to usual care (specialist: RR 1.73, 95% CI 1.55 to 1.93, 28 trials; usual provider: RR 2.41, 95% CI 1.91 to 3.02, 8 trials) but this was largely attributable to the small effect size in two trials using specialist counsellors where the take-up of the planned intervention was low, and one usual provider trial with alarge effect. There was little indirect evidence that the relative effect of an intervention differed according to whether participants in a trial were required to be motivated to make a quit attempt or not. There was only weak evidence that studies offering more sessions had larger effects and there was not clear evidence that increasing the duration of contact increased the effect, but there was more evidence of a dose-response relationship when analyses were limited to trials where the take-up of treatment was high. AUTHORS' CONCLUSIONS Interventions that combine pharmacotherapy and behavioural support increase smoking cessation success compared to a minimal intervention or usual care. Further trials would be unlikely to change this conclusion. We did not find strong evidence from indirect comparisons that offering more intensive behavioural support was associated with larger treatment effects but this could be because intensive interventions are less likely to be delivered in full.
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Affiliation(s)
- Lindsay F Stead
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
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Mackowick KM, Lynch MJ, Weinberger AH, George TP. Treatment of tobacco dependence in people with mental health and addictive disorders. Curr Psychiatry Rep 2012; 14:478-85. [PMID: 22821177 PMCID: PMC3722553 DOI: 10.1007/s11920-012-0299-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
People with mental health and addictive disorders (MHADs) have higher rates of cigarette smoking, and less success in quitting smoking compared with the general population. Moreover, tobacco-related medical illness may be the leading cause of death in the MHAD population. We discuss the scope of this comorbidity, and approaches to the treatment of tobacco dependence in people with MHAD, including schizophrenia, mood disorders, anxiety disorders, and alcohol and substance use disorders. Finally, at the level of health systems, we emphasize the importance of integrated treatment of tobacco dependence in MHADs.
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Affiliation(s)
- Kristen M. Mackowick
- Intramural Research Program, National Institute on Drug Abuse (NIDA), National Institutes of Health (NIH), Baltimore, MD USA; Institute of Medical Sciences, University of Toronto, Toronto, ON Canada
| | - Marie-Josee Lynch
- Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto; Schizophrenia Program, Centre for Addiction and Mental Health (CAMH), Toronto, ON Canada
| | - Andrea H. Weinberger
- Division of Substance Abuse, Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA
- Cancer Prevention and Control Research Program, Yale Cancer Center, New Haven, CT USA
| | - Tony P. George
- Division of Brain and Therapeutics, Department of Psychiatry, University of Toronto; Schizophrenia Program, Centre for Addiction and Mental Health (CAMH), Toronto, ON Canada
- Division of Substance Abuse, Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA
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Grana RA, Ramo DE, Fromont SC, Hall SM, Prochaska JJ. Correlates of tobacco dependence and motivation to quit among young people receiving mental health treatment. Drug Alcohol Depend 2012; 125:127-31. [PMID: 22560677 PMCID: PMC3419328 DOI: 10.1016/j.drugalcdep.2012.04.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2011] [Revised: 03/26/2012] [Accepted: 04/04/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Young people with mental health concerns are at high-risk for initiation and continuation of tobacco use. To inform treatment needs, the current study sought to describe tobacco dependence, motivations to quit and associated sociodemographic factors among young people seen in mental health settings. METHODS Sixty adolescent and young adult smokers (age mean=19.5 years, range 13-25) receiving outpatient mental health treatment completed measures of tobacco dependence, motivation to quit smoking, mental health, and social environmental factors. RESULTS Participants averaged 8.0 cigarettes per day (SD=6.6) and moderate nicotine dependence (mFTQ M=4.8, SD=1.6). Participants' mean rating (10-point scales) of perceived difficulty with avoiding relapse during a quit attempt was significantly higher (M=6.7, SD=2.6), than ratings of desire (M=5.1, SD=2.6) and perceived success (M=4.6, SD=2.6) with quitting. Over half (52%) did not intend to quit smoking in the next 6 months, and few (11%) were prepared to quit in the next 30 days. Mental health treatment and symptomatology measures were unrelated to level of dependence or motivation to quit. Among the social environmental factors, having close friends who smoke was associated with greater perceived difficulty with avoiding relapse during a quit attempt (r=0.25, p<0.01). CONCLUSIONS In this sample of adolescent and young adult smokers in mental health treatment, moderate levels of tobacco dependence and motivation to quit were observed and found to be unrelated to mental health measures. Over half of the sample was not intending to quit smoking in the near future, supporting the need for treatment strategies aimed at increasing motivation.
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Affiliation(s)
- Rachel A. Grana
- University of California, San Francisco, Cardiovascular Research Institute, Center for Tobacco Control Research and Education
| | - Danielle E. Ramo
- University of California, San Francisco, Department of Psychiatry
| | - Sebastien C. Fromont
- University of California, San Francisco, Department of Psychiatry,San Francisco General Hospital, Psychiatric Emergency Services
| | - Sharon M. Hall
- University of California, San Francisco, Department of Psychiatry
| | - Judith J. Prochaska
- University of California, San Francisco, Cardiovascular Research Institute, Center for Tobacco Control Research and Education,University of California, San Francisco, Department of Psychiatry
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Development of a Brief Motivational Intervention to Facilitate Engagement of Smoking Cessation Treatment Among Inpatient Depressed Smokers. J Smok Cessat 2012. [DOI: 10.1017/jsc.2012.3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Inpatient smokers with major depressive disorder (MDD) have high rates of relapse to smoking after hospital discharge. The risk of health consequences that may contribute to increased morbidity and mortality among this population underscores the need to develop a program for psychiatric inpatient cigarette smokers with MDD. Using a motivational interviewing (MI) intervention, we sought to facilitate engagement of smokers with elevated depression symptoms in an outpatient treatment with demonstrated efficacy for nicotine dependence. In Phase 1 of this program, we recruited 15 smokers with MDD who were receiving inpatient psychiatric services. This preliminary report focuses on the development of the intervention, and explores perceived barriers to quitting, methods of quitting, and interest in smoking cessation treatment following discharge from an inpatient stay. Understanding inpatient cigarette smokers’ interests in making changes in smoking, and in willingness to attempt cessation and engage in cessation treatment can inform efforts to curb smoking in this high-risk population.
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12
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Hebert KK, Cummins SE, Hernández S, Tedeschi GJ, Zhu SH. Current major depression among smokers using a state quitline. Am J Prev Med 2011; 40:47-53. [PMID: 21146767 PMCID: PMC3006168 DOI: 10.1016/j.amepre.2010.09.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2010] [Revised: 06/21/2010] [Accepted: 09/03/2010] [Indexed: 01/30/2023]
Abstract
BACKGROUND Smokers seeking treatment to quit smoking are generally not assessed for current depression, yet depression among smokers may influence quitting outcome. PURPOSE This study aims to formally assess current major depression among smokers calling a state tobacco quitline. METHODS A total of 844 smokers calling the California Smokers' Helpline in 2007 were screened for depression by the mood module of the Patient Health Questionnaire (PHQ-9). The Social Functioning Questionnaire (SFQ) also was administered to these callers. Two months after the screening, follow-up evaluations were conducted to assess cessation outcome. RESULTS In all, 24.2% of smokers met criteria for current major depression and 16.5% reported symptoms indicating mild depression. Callers with current major depression were more likely to be heavy smokers and on Medicaid. Moreover, 74.0% of smokers with current major depression had substantial social and occupational functioning deficits. Two months later, those with major depression at baseline were significantly less likely to have quit smoking (18.5% vs 28.4%). CONCLUSIONS Almost one in four smokers who called the California Smokers' Helpline met criteria for current major depression. More than 400,000 smokers call state quitlines in the U.S. for help with quitting each year, which means that as many as 100,000 smokers with serious depressive symptoms are using these services annually. The large number of depressed smokers who seek help suggests a need to develop appropriate interventions to help them quit successfully.
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Affiliation(s)
- Kiandra K Hebert
- Moores Cancer Center, University of California San Diego, La Jolla, 92093-0905, USA
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Hitsman B, Moss TG, Montoya ID, George TP. Treatment of tobacco dependence in mental health and addictive disorders. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2009; 54:368-78. [PMID: 19527557 PMCID: PMC3632078 DOI: 10.1177/070674370905400604] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
People with mental health and addictive (MHA) disorders smoke at high rates and require tobacco treatment as a part of their comprehensive psychiatric care. Psychiatric care providers often do not address tobacco use among people with mental illness, possibly owing to the belief that their patients will not be able to quit successfully or that even short-term abstinence will adversely influence psychiatric status. Progress in the development of treatments has been slow in part because smokers with current MHA disorders have been excluded from most smoking cessation trials. There are several smoking cessation treatment options, including psychological and pharmacological interventions, that should be offered to people with an MHA disorder who smoke. Building motivation and readiness to quit smoking is a major challenge, and therefore motivational interventions are essential. We review the treatment options for people with tobacco dependence and MHA disorders, offer recommendations on tobacco assessment and tailored treatment strategies, and provide suggestions for future research. Treatment efficacy could be enhanced through promoting smoking reduction as an initial treatment goal, extending duration of treatment, and delivering it within an integrated care model that also aims to reduce the availability of tobacco in MHA treatment settings and in the community.
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Affiliation(s)
- Brian Hitsman
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois 60611, USA.
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Abstract
BACKGROUND People with mental health (MH) disorders smoke at higher rates, are more nicotine-dependent and suffer greater morbidity and mortality from smoking-related illnesses than the general population. Helping these people to quit smoking is a public health priority; however, many MH professionals assume that those with mental illness are not motivated to quit. OBJECTIVES To use predetermined criteria to identify, review critically and evaluate empirically all English language, peer-reviewed data on motivation to quit smoking in MH populations. METHODS A systematic search was conducted and key data on subject characteristics, measures of motivation and other variables abstracted. chi(2) analyses were used to compare motivation between MH and general populations, between in-patients and out-patients and between people with depression and people with psychotic disorders. RESULTS Evidence suggests that people with MH disorders are as motivated to quit smoking as the general population, although those with psychotic disorders may be less motivated than individuals with depression. Although readiness to cease smoking was assessed in 14 studies, only two evaluated motivation to quit smoking in in-patient populations. CONCLUSIONS People with MH disorders are motivated to quit smoking, although more research is needed looking at in-patient populations. The commonly held false belief that people with MH disorders are not motivated to cease smoking means that opportunities to encourage smoking cessation among this disenfranchised group are being missed.
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Affiliation(s)
- Ranita Siru
- School of Psychiatry and Clinical Neurosciences, University of Western Australia, QE II Medical Centre, Nedlands, WA, Australia
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15
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Floyd AHL, Westmaas JL, Targhetta V, Moyer A. Depressive symptoms and smokers' perceptions of lung cancer risk: moderating effects of tobacco dependence. Addict Behav 2009; 34:154-63. [PMID: 18977092 DOI: 10.1016/j.addbeh.2008.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2008] [Revised: 09/05/2008] [Accepted: 10/01/2008] [Indexed: 11/30/2022]
Abstract
Smokers who acknowledge the personal health risks of smoking are more likely to attempt quitting. Unfortunately, many smokers are unrealistically optimistic about their health risks. Depressed smokers, however, may be more realistic about their risks. These studies examined the relationship between depressive symptoms and risk perceptions among two groups: college-age smokers (N = 128) and smokers from the nationally representative HINTS database (N = 1,246). In the college sample, among highly tobacco dependent smokers, more depressed smokers believed more strongly that quitting eliminates lung cancer risk (b = - .27, p = .01), and they estimated a faster reversal of risk after quitting (b = - .70, p = .03). In the HINTS sample, among highly tobacco dependent women, the more depressed they were, the higher their perceived risk of developing lung cancer (b = .23, p = .05). In sum, depressive symptoms among some smokers may lead to heightened risk perceptions. However the belief that quitting can reduce risk quickly might encourage smokers to postpone quitting. Cessation programs could benefit from tailoring their programs accordingly.
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Affiliation(s)
- Anna H L Floyd
- Department of Psychology, Stony Brook University, Stony Brook, NY 11794-2500, USA.
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16
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Abstract
BACKGROUND There is a close relationship between tobacco smoking and psychiatric disorders, and a higher proportion of individuals with mental health conditions smoke compared with the general population. Due to the increased smoking prevalence in this population, patients with psychiatric conditions are at greater risk of smoking-related morbidity and mortality and experience detrimental effects on their quality of life. However, while the majority of individuals with a history of mental health conditions appreciate that smoking is detrimental to their health, they are less likely to quit smoking and have a lower success rate during quit attempts compared with the general population. SCOPE Peer-reviewed articles were identified from PubMed using the inclusive date-range of 1990 - October 2008 and the search terms; depression, mental health, psychiatric disorders, schizophrenia, and smoking cessation. Articles were selected from the search results to provide a general overview of some of the main issues for smokers with psychiatric disorders in general and specifically, those with schizophrenia and depression. The evidence from smoking cessation trials within these populations was also reviewed. FINDINGS Nicotine has some positive effects on symptoms of psychiatric disorders and it has been proposed that patients with mental health conditions may smoke as a form of self-medication. Further, several studies have shown that some symptoms of psychiatric disorders may be exacerbated by nicotine withdrawal. Therefore, attempts to quit smoking pose additional problems to patients with mental health problems. CONCLUSION Traditional programmes for smoking cessation may not always be suitable for psychiatric patients due to their neuropsychological profile. Preliminary evidence suggests that more flexible, open-ended, combination approaches of pharmacotherapy and counselling may be more successful. In addition, identification and treatment of nicotine addiction remains very low in patients with mental health conditions and far more needs to be done to raise the awareness and ability of psychiatrists to diagnose and treat patients with nicotine problems.
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Affiliation(s)
- Karl Fagerström
- Smokers Information Centre, Fagerström Consulting AB, Helsingborg, Sweden.
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A controlled trial of bupropion added to nicotine patch and behavioral therapy for smoking cessation in adults with unipolar depressive disorders. J Clin Psychopharmacol 2008; 28:660-6. [PMID: 19011435 PMCID: PMC3505846 DOI: 10.1097/jcp.0b013e31818ad7d6] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although there is a strong relationship between depression and smoking, most nicotine dependence treatment trials exclude depressed smokers. Our objective was to determine whether bupropion improves abstinence rates and abstinence-associated depressive symptoms when added to transdermal nicotine replacement therapy (NRT) and group cognitive behavioral therapy (CBT) in smokers with unipolar depressive disorder (UDD). Adult smokers with current (n = 90) or past (n = 109) UDD were randomly assigned to receive bupropion or placebo added to NRT and CBT for 13 weeks. In the primary analysis, with dropouts considered smokers, 36% (35/97) of those on bupropion and 31% (32/102) on placebo attained biochemically validated 7-day point prevalence abstinence at end of treatment (not significant). Because of a high dropout rate (50%) and a significant difference in abstinence status at dropout by treatment group, a traditional intent-to-treat analysis with last observation carried forward imputation of abstinence status was performed. In this secondary analysis, 56% (54/97) of those on bupropion and 41% (42/102) on placebo met criteria for abstinence at end of trial, chi2 = 4.18, P = 0.04. Nicotine replacement therapy usage and absence of a comorbid anxiety disorder predicted abstinence. Abstinence was associated with increased depressive symptoms, regardless of bupropion treatment. Thus, in the primary analysis, bupropion neither increased the efficacy of intensive group CBT and NRT for smoking cessation in smokers with UDD nor prevented abstinence-associated depressive symptoms. Bupropion seemed to provide an advantage for smoking cessation for those who remained in the trial. The dropout rate was high and was characterized by a higher prevalence of current comorbid anxiety disorder. Given the high abstinence rate achieved with CBT plus NRT, a ceiling effect related to the high level of intervention received by all subjects may have prevented an adequate test of bupropion.
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MacPherson L, Stipelman BA, Duplinsky M, Brown RA, Lejuez CW. Distress tolerance and pre-smoking treatment attrition: examination of moderating relationships. Addict Behav 2008; 33:1385-1393. [PMID: 18706768 DOI: 10.1016/j.addbeh.2008.07.001] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2008] [Revised: 06/24/2008] [Accepted: 07/07/2008] [Indexed: 11/30/2022]
Abstract
This study focused on the understudied group of smokers who commit to a smoking research study and then subsequently drop out before completing even one session of treatment (pre-inclusion attrition). This is an important group typically not examined in their own right, leaving little knowledge about the characteristics that differentiate them from those who complete treatment. As an initial investigation, the current study examined affective risk factors for attrition in a sample of 53 adults (79% African-American; median income=$30,000-$39,999) enrolled in a smoking cessation study. Twenty-one (40%) participants never attended a session of treatment. Results indicated that lower psychological distress tolerance was related to pre-inclusion attrition, but only among women. Additionally, lower physical distress tolerance corresponded to pre-inclusion attrition, but only among men. These effects remained after including other important affective factors such as anxiety sensitivity and current depressive symptoms. No other predictors examined corresponded with pre-inclusion attrition in the present sample. Results indicate the need for more research attention to this at-risk group of smokers who do not continue on to cessation intervention.
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Affiliation(s)
- Laura MacPherson
- Department of Psychology and the Center for Addictions, Personality, and Emotion Research University of Maryland, College Park, MD 20742, USA.
| | - Brooke A Stipelman
- Department of Psychology and the Center for Addictions, Personality, and Emotion Research University of Maryland, College Park, MD 20742, USA
| | - Michelle Duplinsky
- Department of Psychology and the Center for Addictions, Personality, and Emotion Research University of Maryland, College Park, MD 20742, USA
| | - Richard A Brown
- Alpert Medical School of Brown University and Butler Hospital, Providence, RI, USA
| | - C W Lejuez
- Department of Psychology and the Center for Addictions, Personality, and Emotion Research University of Maryland, College Park, MD 20742, USA
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Hall SM, Tsoh JY, Prochaska JJ, Eisendrath S, Rossi JS, Redding CA, Rosen AB, Meisner M, Humfleet GL, Gorecki JA. Treatment for cigarette smoking among depressed mental health outpatients: a randomized clinical trial. Am J Public Health 2006; 96:1808-14. [PMID: 17008577 PMCID: PMC1586139 DOI: 10.2105/ajph.2005.080382] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Using a brief contact control, we tested the efficacy of a staged care intervention to reduce cigarette smoking among psychiatric patients in outpatient treatment for depression. METHODS We conducted a randomized clinical trial that included assessments at baseline and at months 3, 6, 12, and 18. Three hundred twenty-two patients in mental health outpatient treatment who were diagnosed with depression and smoked > or =1 cigarette per day participated. The desire to quit smoking was not a prerequisite for participation. Staged care intervention participants received computerized motivational feedback at baseline and at 3, 6, and 12 months and were offered a 6-session psychological counseling and pharmacological cessation treatment program. Brief contact control participants received a self-help guide and referral list of local smoking-treatment providers. RESULTS As we hypothesized, abstinence rates among staged care intervention participants exceeded those of brief contact control participants at months 12 and 18. Significant differences favoring staged care intervention also were found in occurrence of a quit attempt and stringency of abstinence goal. CONCLUSION The data suggest that individuals in psychiatric treatment for depression can be aided in quitting smoking through use of staged care interventions and that smoking cessation interventions used in the general population can be implemented in psychiatric outpatient settings.
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Affiliation(s)
- Sharon M Hall
- University of California, San Francisco, Treatment Research Center,San Francisco, CA 94143, USA.
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