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

The Whole Package: A Multi-Component Smoking Cessation Intervention for Adults With Serious Mental Illness: A Qualitative Study

Introduction: Smoking is one of the most important modifiable risk factors for excess morbidity and mortality in adults with serious mental illness (SMI). Many smokers with SMI are reportedly motivated to quit, however success rates among these smokers remain low and evidence-based treatment targeting this vulnerable group is limited. The purpose of this paper is to report the results of a qualitative inquiry of participants. Methods: We conducted a pilot two-arm randomized controlled trial (RCT) targeting adults with SMI. Our smoking cessation intervention included: (a) group-based physical activity (PA) game intervention (50 minutes, 3X/week for 12 weeks), (b) pharmacotherapy (bupropion or nicotine replacement therapy), and (c) smoking cessation counseling. Upon completion of the program, participants in the active and control groups completed a qualitative semi-structured interview in order to determine how the program impacted their smoking cessation. Grounded Theory methodology guided our data collection and analysis. Results: Twenty participants completed an interview. Participants described how the "whole package" of the 3 components of the intervention were critical to their smoking cessation process. The group-based program provided the structure, resources, and encouragement needed to start the process of quitting. Conclusion: Adults with SMI need support, resources, and engaging activities as they begin quitting and practice the skills needed to quit.

The Impact of a Nurse-Led Service on Tobacco Treatment Provision Within a Psychiatric Hospital: A Time Series Study

INTRODUCTION

Psychiatric hospitalization is an opportunity to provide evidence-based tobacco treatment to optimize cessation efforts among people living with mental illnesses (MI). The purpose of this study was to examine the effectiveness of nurse-driven initiatives to enhance tobacco treatment within an inpatient psychiatric setting.

AIMS

We assessed the 4-year impact of implementing a nurse-led tobacco treatment service offered to 11,314 inpatients at admissions in a tobacco-free psychiatric facility in Kentucky.

METHOD

Through a time-series design, we compared the differences in rates of screening for tobacco use and providing treatment from September to December 2015 (prior to implementing the nurse-led tobacco treatment services) to each subsequent year in a 4-year period (2016-2019).

RESULTS

Approximately 60.0% of inpatients were persons using tobacco during the assessment period. Although there were no changes in tobacco use prevalence over the 4-year evaluation duration, there were significant increases in the provision of practical counseling and Food and Drug Administration-approved nicotine replacement therapies for persons using tobacco.

CONCLUSIONS

Our findings support the effectiveness of implementing tobacco treatment programs at the organizational level. Psychiatric hospitalizations provide an opportunity to optimize nurse-driven efforts to deliver tobacco treatment to people with MI. Similar models of nurse-led tobacco treatment services can be adopted within inpatient and other mental and behavioral health settings.

Smoking Cessation Barriers among Individuals with Mental Illnesses: A Qualitative Study of Patients' and Healthcare Providers' Perspectives

In this paper we aimed to explore: (1) challenges that people with mental illnesses (MIs) describe in engaging in smoking cessation, (2) challenges that mental health providers (MHPs) perceive that people living with MIs face, and (3) how the perceived challenges are similar and/or different from both perspectives. Semi-structured interviews were used to obtain narrative data from 16 MHPs and 13 psychiatric inpatients with MIs. We identified themes purport societal, group, and individual factors may influence smoking cessation treatment engagement. The scope of the perceived challenges appeared varied in the narratives of MHPs as compared to those with MI.

Initiating Pharmacologic Treatment in Tobacco-Dependent Adults

There is a strong evidence base for the use of existing pharmacotherapies to support tobacco cessation, alone or in combination, ideally with concurrent behavioral interventions. Future pharmacotherapies under development may assist in the most refractory cases. Incorporating current and future therapies into a longitudinal chronic care model for tobacco dependence will help a diverse range of patients achieve independence from nicotine addiction.

The effect of a real-world intervention for smoking cessation in Adults with and without comorbid psychiatric and substance use disorders: A one-year follow-up study

This study evaluated short-term abstinence and prolonged abstinence following a real-world intervention for smoking cessation in a sample of 1,213 adults with nicotine dependence only (ND), nicotine dependence and past history of another substance use disorder (ND-SUD), nicotine dependence and a non-substance use mental health disorder (ND-MD), or nicotine dependence and comorbid substance use disorder and mental health disorder (ND-SUMD). Participants received six sessions of group Cognitive Behavioral Therapy (CBT) and pharmacotherapy. Abstinence was assessed following completion of treatment and at 12-month follow-up. Logistic regression and survival analyses were performed. Participants who were lost to follow-up were included as censored and baseline differences were used as covariates in multivariate analyses. Rates of short-term abstinence and prolonged abstinence were significantly different between ND and ND-SUMD (20.9% versus 36.5%; 14.9% versus 22.4%, respectively). Among participants with follow-up, 37.7% were abstinent at 12-month. Diagnostic group was not associated with abstinence at 12-month follow-up after adjusting for nicotine dependence severity, which was associated with lower likelihood of abstinence (HR=1.11;95%CI:1.03-1.19). CBT plus pharmacotherapy had a positive effect on smoking cessation among the participants in this study. Special attention should be given to adults with more severe nicotine dependence and comorbid psychiatric and substance use disorders.

TOBACCO USE DISORDER AND DUAL DISORDERS Joint statement by the Spanish Psychiatry Society and the Spanish Dual Disorders Society

Tobacco Use Disorder (TUD) is a health problem of the first order in the world population, affecting a vulnerable population, such as people with other mental disorders, whose morbidity and mortality are increased as a result.

Treatment pearls: Management of physical healthcare needs in patients with mental illness

ABSTRACT

Clinicians caring for persons with mental illness should be aware of increased mortality, physical problems, and health disparities in this population. This article provides a brief overview of physical health problems in the context of mental illness as well as those related to psychotropic medications, and discusses strategies to manage treatment effectively.

Telephone based smoking cessation intervention for adults with serious mental illness during the COVID-19 pandemic

Background

The high rates of smoking in adults with serious mental illness (SMI) increases risk for COVID-19 infection. The purpose of this paper is to present the results of a smoking cessation intervention that was adapted to be offered by phone during a Shelter in Place (SIP) period in San Francisco, California, at the beginning of the COVID-19 pandemic.

Methods

During the SIP, we offered counseling sessions by phone to five participants. At the end of each session, we assessed readiness to quit, tobacco cessation or reduction, and inquired about the impact of the shelter in place on smoking habits and mental health. Grounded theory guided data collection and analysis.

Results

The categories that emerged around barriers and facilitators for smoking cessation were COVID-19-related stressors, having purpose, structure and feelings of connections, and the importance of quitting aides for smoking cessation.

Conclusion

Offering telephone based smoking cessation counseling to adults with SMI while they shelter in place may improve their readiness to quit.

Unique cessation tools in the box: Quitline utilization and effectiveness trends among a large sample of tobacco users reporting mental health disorders

It is estimated that the prevalence of smoking among adults with MHDs ranges between 40-60%, as compared to about 17% among those without an MHD. In addition, smokers with MHDs smoke more cigarettes, are more nicotine dependent, and experience more difficulty quitting, compared to other smokers. The uniquely high smoking prevalence among the MHD population is a serious public health concern; unfortunately, a majority of individuals experiencing difficulty receive no treatment. The US Public Health Service guidelines, as well as the National Cancer Institute, strongly recommend quitlines as an evidence-based treatment strategy to reduce barriers to cessation treatment, especially among smokers with MHDs; however, the literature is sparse on quitline engagement trends and associated outcomes for quitline participants with MHDs. This study sought to contribute to this gap with the largest sample to-date of MHD-endorsing tobacco quitline (Oklahoma Tobacco Helpline, OTH) participants. From 2015 to 2020, ~65,000 registrants (45-50% of total registered participants) with the OTH identified as having one or more MHDs in addition to their tobacco use. This study tested for the presence of significant differences between groups with and without MHDs (as well as within the MHD-identified group) on program enrollment selections, the intensity of engagement with chosen services, NRT utilization, and quit rates. It also tested for the existence of differences and moderating effects of demographic variables associated with the comparison groups. Statistically significant differences were found between these two groups with regard to: sex, age, racial identity, education level, annual income and insurance status. Significant differences were also found with tobacco use patterns reported by individuals (e.g., timing and daily use amounts). Differences in quitline program selection were demonstrated, such that the MHD-endorsing sample were more likely to participate and agree to the most robust service available. Significantly higher rates of service intensity (number of services engaged) were demonstrated, and MHD individuals were also significantly more likely to receive NRT as a part of their treatment. This study suggests a simplistic "more is better" quitline services approach may suffer in effectiveness because it neglects barriers common to this population. Important information is provided on these unique variables associated with MHD-endorsing individuals trying to quit their tobacco use. These results can help tobacco quitlines conceptualize the unique difficulties experienced by individuals with MHDs and then tailor their approach to respond supportively and constructively to this high need group.

Smoking and nicotine dependence in relation to depression, anxiety, and stress in Egyptian adults: A cross-sectional study

BACKGROUND

Much research has found that smoking is one of the major risk factors for a variety of physical diseases and mental disorders; however, few studies have been conducted on smoking in Egypt. Furthermore, to the researcher's best knowledge, no study in Egypt has compiled data on smoking prevalence, motives, and levels of nicotine dependency. In order to fill in this gap, the current study has attempted to summarize the situation and construct an accurate picture of smoking in Egypt.

MATERIALS AND METHODS

This cross-sectional study included 2000 Egyptian adults in Fayoum through a multistage cluster sampling technique. For data collection, the Socioeconomic Status Scale was deployed. In addition, Depression, Anxiety, Stress Scale (DASS), the Modified Reasons for Smoking Scale (MRSS), and Fagerstrom Test for Nicotine Dependence (FTND) were used. Data analysis performed using SPSS version 22.0. For qualitative data, Chi-square test was used to determine statistical significance. Bivariate Pearson correlation was used to test for the association between quantitative variables.

RESULTS

Of the total sample of 2000 adults, 40.4% had anxiety and 24.3% had stress, and 19.5% showed severe to extremely severe level of depression. For MRSS, tension reduction or relaxation was found in 46.5% adults while 9.8% had high level of nicotine dependence. There was a statistically significant association between psychometric disorders, on one hand, and both smoking motivation and nicotine dependence, on the other (P < 0.001). The DASS score had a statistically significant correlation with age, smoking duration, nicotine dependence level, and MRSS subscales.

CONCLUSION

Smoking is linked to psychological symptoms and shows a moderate to high level of nicotine dependence, with a higher level of dependency, smoking pleasure, stress reduction/ relaxation, and hand-mouth movement as motives for smoking. Furthermore, there was a correlation between nicotine dependence, on one hand, and depression and stress on the other.

There's no smoke without fire: Smoking in smoke-free acute mental health wards

BACKGROUND

People who smoke with serious mental illness carry disproportionate costs from smoking, including poor health and premature death from tobacco-related illnesses. Hospitals in New Zealand are ostensibly smoke-free; however, some mental health wards have resisted implementing this policy.

AIM

This study explored smoking in acute metal health wards using data emerging from a large sociological study on modern acute psychiatric units.

METHODS

Eighty-five in-depth, semi-structured interviews were conducted with staff and service users from four units. Data were analysed using a social constructionist problem representation approach.

RESULTS

Although high-level smoke-free policies were mandatory, most participants disregarded these policies and smoking occurred in internal courtyards. Staff reasoned that acute admissions were not the time to quit smoking, citing the sceptres of distress and possibly violence; further, they found smoking challenging to combat. Inconsistent enforcement of smoke-free policies was common and problematic. Many service users also rejected smoke-free policies; they considered smoking facilitated social connections, alleviated boredom, and helped them feel calm in a distressing environment - some started or increased smoking following admission. A minority viewed smoking as a problem; a fire hazard, or pollutant. No one mentioned its health risks.

CONCLUSION

Psychiatric wards remain overlooked corners where hospital smoke-free policies are inconsistently applied or ignored. Well-meaning staff hold strong but anachronistic views about smoking. To neglect smoking cessation support for people with serious mental illness is discriminatory and perpetuates health and socioeconomic inequities. However, blanket applications of generic policy are unlikely to succeed. Solutions may include myth-busting education for service users and staff, local champions, and strong managerial support and leadership, with additional resourcing during transition phases. Smoke-free policies need consistent application with non-judgemental NRT and, potentially, other treatments. Smoking cessation would be supported by better designed facilities with more options for alleviating boredom, expressing autonomy, facilitating social connections, and reducing distress.

Systematic Review of Psychosocial Smoking Cessation Interventions for People with Serious Mental Illness

Tobacco smoking is a major driver of premature mortality in people with serious mental illness (SMI; e.g., schizophrenia, bipolar disorder). This systematic literature review described randomized control trials of psychosocial smoking cessation interventions for people with SMI, rated their methodological rigor, evaluated the inclusion of racial/ethnic and sexual/gender minorities, and examined smoking cessation outcomes. Methods: Eligible studies included peer-reviewed articles published between 2009 and 2020 that examined psychosocial smoking cessation interventions in people with SMI. We used the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines to conduct our review and the Methodological Quality Rating Scale to evaluate methodological rigor. Results: Eighteen studies were included. Ten were categorized as high methodological rigor given their study characteristics (e.g., longer follow-up) and eight as lower methodological rigor based on their characteristics (e.g., not intent-to-treat). Racial/ethnic and sexual/gender minorities were under-represented in these studies. A range of psychosocial interventions were examined including motivational enhancements, smoking cessation education, cognitive behavioral strategies, and contingency management. Most studies also provided smoking cessation medications (e.g., NRT, bupropion), although provision was not always uniform across treatment conditions. Three studies found the intervention condition achieved significantly higher abstinence from smoking compared to the comparison group. Seven studies found the intervention condition achieved significantly higher reductions in smoking compared to the comparison group. Conclusions: Studies finding significant differences between the intervention and comparison groups shared common evidenced-based components, including providing smoking cessation medications (e.g., NRT, bupropion), motivational enhancement techniques, and cessation education and skills training, but differed in intensity (e.g., number and frequency of sessions), duration, and modality (e.g., group, individual, technology). Methodological limitations and a small number of studies finding significant between-group differences prevent the identification of the most effective psychosocial smoking cessation interventions. Clinical trial designs (e.g., SMART, factorial) that control for the provision of psychosocial medications and allow for the identification of optimal psychosocial treatments are needed. Future studies should also ensure greater inclusion of racial/ethnic and sexual/gender minorities and should be culturally/linguistically adapted to improve treatment engagement and study outcomes.

Dynamic associations between anxiety, depression, and tobacco use in older adults: Results from The Irish Longitudinal Study on Ageing

Evidence supports moderate-to-large reductions in anxiety, depression, and perceived stress after smoking cessation; however, much of the available evidence has focused on young adults. Therefore, this study quantified associations between smoking and smoking cessation on prevalent and incident generalised anxiety disorder (GAD) and major depression (MDD) in a nationally representative sample of Irish older adults. Participants (n = 6201) were community dwelling adults aged ≥50 years resident in Ireland. Smoking status and self-reported doctor diagnosis of anxiety or depression prior to baseline were assessed at baseline (i.e., Wave 2). At baseline and 2-, 4-, and 6-year follow-up (i.e., Waves 3-5), GAD and MDD were assessed by the Composite International Diagnostic Interview Short-Form. Logistic regression quantified cross-sectional and prospective associations (odds ratios (ORs) and 95% confidence intervals (95%CIs)) between smoking status and mental health. Prevalence and incidence of GAD was 9.1% (n = 566) and 2.8% (n = 148), respectively. Prevalence and incidence of depression was 11.1% (n = 686) and 6.4% (n = 342), respectively. Following full adjustment, current smokers had higher odds of prevalent GAD (OR = 1.729, 1.332-2.449; p < 0.001) and MDD (OR = 1.967, 1.548-2.499; p < 0.001) than non-smokers. Former smokers had higher odds of prevalent GAD than non-smokers (OR = 1.276, 1.008-1.616; p < 0.001). Current smokers did not have higher odds of incident MDD (OR = 1.399, 0.984-1.990; p = 0.065) or GAD than non-smokers (1.039, 0.624-1.730; p = 0.881). Findings may have important implications for interventions designed to curb tobacco abuse, which tend to be less successful among those with anxiety and depression.

The right to smoke and the right to smoke-free surroundings: international comparison of smoke-free psychiatric clinic implementation experiences

BACKGROUND

In Scandinavia, people with a severe mental disorder have a reduced life expectancy of 15-20 years compared with the general public. Smoking is a major contributor, and smoke-free policies are increasingly adopted in psychiatric clinics around the world. We compared potential facilitators and barriers among staff and management, for the implementation of smoke-free psychiatric clinics.

AIMS

To investigate the attitudes and experiences regarding smoke-free policies among managers and staff involved in the implementation processes of smoke-free psychiatric clinics at hospitals in Malmö (Sweden) and Barcelona (Spain).

METHOD

We used a qualitative methodology, with 15 semi-structured interviews. The interviews were conducted with each participant individually, and were subsequently transcribed. The data were analysed with systematic text condensation.

RESULTS

There were notable differences in how the smoke-free policies were carried out and experienced, and attitudes regarding the policy changes differed in the two settings. Key differences were the views on the right to smoke in compulsory care and to stay in smoke-free surroundings supported by smoking cessation intervention; the prioritisation of staff facilitation of smoking breaks; and views on smoking and smoke-free psychiatry. In contrast, participants agreed on the importance of staff education and management support. A smoking ban by law and belonging to a network of smoke-free hospitals were also relevant.

CONCLUSIONS

Staff education, and support from staff and management for the patients' right to stay in smoke-free surroundings, facilitated successful implementation of smoke-free policies in the psychiatric clinics, whereas supporting the right to smoke was a barrier.

CYP1A2 and tobacco interaction: a major pharmacokinetic challenge during smoking cessation

Smoking cessation is underestimated in terms of drug interactions. Abrupt smoking cessation is common in cases of emergency hospitalization and restrictions of movement. Tobacco is a known cytochrome P450 1A2 (CYP1A2) inducer, its consumption and withdrawal can lead to major pharmacokinetic drug interactions. Nevertheless, references do exist, but may have different results between them. The objective of our work was to establish the broadest and most consensual list as possible of CYP1A2 substrates treatments and propose a pharmacological approach. We searched the widest possible list of CYP1A2 substrates based on various international references. We compared the references and defined probability and reliability scores of our results to sort the substances based on the scores. For the 245 substances identified as CYP1A2 substrates, we focused on the 63 CYP1A2 substrates with both probability and reliability scores >50%. Our work establishes adaptive pharmacological approaches for the management of patients initiating smoking cessation which must be integrated into the management of smoking cessation. Pharmacologists can now adopt adaptive pharmacological approaches to complement patient-specific clinical information about smoking cessation by considering pharmacokinetic risk. This work establishes an unprecedented list. It should guide in the care of patients initiating smoking cessation to prevent pharmacokinetic drug interactions.

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.

Factors associated with tobacco cessation attempts among inpatients in a psychiatric hospital

Introduction

Several effective evidence-based tobacco treatment approaches can optimize cessation attempts; however, little is known about the utilization of such strategies by people with mental illnesses (MI) during their cessation attempts.

Aims

To examine methods used during and factors associated with tobacco cessation attempts among people with MI.

Methods

Self-administered cross-sectional survey data were obtained from 132 tobacco using inpatients from a psychiatric facility in Kentucky, USA.

Results

Our study found ‘cold turkey’ as the most reported method by inpatient tobacco users with MI in their prior cessation attempts regardless of the psychiatric diagnosis category. Multivariate logistic regression found ethnicity (OR 26.1; 95% CI 2.9–237.1), age at 1st smoke (OR 1.1; 95% CI 1.0–1.1), importance to quit (OR 1.2; 95% CI 1.0–1.4), and receipt of brief tobacco treatment interventions (OR 1.1; 95% CI 1.0–1.3) significantly associated with quit attempt in the past year.

Conclusion

Despite the existence of various evidence-based approaches to enhance tobacco cessation among people with MI, ‘cold-turkey’ was the most preferred method in this sample. In addition, this study highlighted ethnicity, importance to quit, age at 1st smoke, and receipt of brief interventions as important factors to consider when tailoring tobacco cessation in this population. Though ethnicity is a non-modifiable factor, an informed provider may intervene skillfully by addressing socio-cultural barriers specific to an ethnic group. Lower ratings on the motivation ruler and early age of smoking initiation could also inform providers when using motivational interviewing and other evidence-based tobacco-cessation approaches.

Impact of implementing a tobacco and recreational nicotine-free policy and enhanced treatments on programmatic and patient-level outcomes within a residential substance use disorder treatment program

BACKGROUND

Recent estimates are that 30% of military veterans use tobacco or recreational nicotine products, and rates significantly increase for veterans with co-occurring substance use disorder (SUD). Despite emerging literature that indicate better outcomes when SUD and tobacco use disorder (TUD) are treated simultaneously (in parallel), most SUD programs fail to address tobacco use. This can prove catastrophic, as perhaps the most likely cause of death lifetime for patients admitted to a SUD treatment program is tobacco/nicotine-related. Studies suggest that residential SUD treatment programs can improve the screening, diagnosis, documentation, and treatment of TUD. Perceived barriers among staff include fear of causing patients to leave early. There are few studies evaluating the accuracy of these perceived barriers to programmatic and patient-level outcomes in the residential SUD treatment setting when TUD services are provided along with a nicotine/tobacco-free therapeutic milieu.

OBJECTIVE

In the fall of 2015, a SUD treatment program at a large midwestern Veteran. Affairs Medical Center fully implemented a tobacco-free residential unit. The current study investigates the programmatic and patient-level outcomes among cohorts treated before versus after the tobacco-free policy was implemented.

PARTICIPANTS & PROCEDURES

This study utilized archival data and all participants were enrolled in the residential program with 117 veterans enrolled pre and 92 post tobacco-free policy. The final sample consisted of 194 males (92.8%), 14 females (6.7%), and 1 transgendered (0.5%) with a mean age of 47.80 (SD = 12.65). Most of the participants were Caucasian (69.4%) and divorced (43.1%). The majority (167, 79.9%) reported current tobacco use, with cigarettes (118, 56.5%) being the most frequently reported type. In addition, 17.59 (SD = 6.51) years old is the average start age of tobacco use.

RESULTS

Veterans in the pre-policy cohort did not differ from post-policy cohort on age, gender, ethnicity, and marital status. Preliminary results related to programmatic outcomes indicate improved rates of TUD diagnosis during intake (28.4% to 75.0%). Similar rates were observed in veterans who reported tobacco quit goal during treatment planning (37.4% to 56.8%). However, while there were no significant differences in the total rates of infractions; tobacco-related infractions significantly increased from one to eight. Finally, there were no significant differences in the number of against medical advice discharges or irregular discharges. Examination of patient-level outcomes revealed similar rates of veterans enrolling in the program as it relates to rates of current tobacco use, admission expired breath carbon monoxide (CO) measured in parts per million (ppm), longest period of tobacco abstinence, and self-reported primary preferred substance/drug. Of note, there were also no differences in reported importance and confidence of quitting tobacco. Rates of veterans prescribed nicotine replacement therapy during residential stay more than doubled.

CONCLUSIONS

Our data suggest that implementing a tobacco-free policy within a residential SUD treatment program would not deter veterans from staying engaged in the program as evident by similar rates of irregular and AMA discharges. In addition, the prevalence of Veterans wishing to quit tobacco was higher in the post-policy cohort, as was NRT utilization, and without the addition of staff. Specific treatment recommendations will be discussed along with other implications.

The Changing Process of Women's Smoking Status Triggered by Pregnancy

Although pregnancy is the trigger for many women to stop smoking, often they are unable to maintain cessation, undoing any health benefits for themselves and their children. Smoking is a complex phenomenon both before and after pregnancy, influenced by social background, relationships, and the specific experience of pregnancy and delivery. Therefore, it is necessary to clarify the experience and process of changes in women's smoking status from pregnancy to after delivery. To explore possibilities for better smoking cessation support, the objective of this study was to clarify the changing process of smoking status from pregnancy to after delivery in women for whom pregnancy triggered a smoking cessation. We analyzed data obtained through semi-structured interviews with 31 women, using the grounded theory approach. Women reconsidered their smoking status, either quitting or smoking fewer cigarettes, because of externally motivated changes due to concerns regarding the influence of smoking on pregnancy and children. To prevent smoking relapse, it is important for the women themselves, as well as those around them, to appreciate their cessation, facilitating internal motivation and assessment of the situation. Furthermore, it is important to provide support, by implementing the process revealed in this study, not only during pregnancy but for an entire lifetime.

Characteristics, outcome and factors associated with success of quitting smoking in 77 people living with HIV/AIDS who received smoking cessation therapy in Japan

AIM

Smokers with HIV/AIDS have lower success of quitting smoking than smokers with other chronic diseases. However, there have been no studies investigating characteristics and outcomes of success of quitting smoking among people living with HIV compared to HIV-negative people who received smoking cessation therapy. In addition, there have been no studies that investigated factors associated with success of quitting smoking among people living with HIV in Japan. The aim of this study was to elucidate characteristics, outcomes and factors associated with the success of quitting smoking in people living with HIV.

METHODS

We previously conducted a prospective cohort study on patients who received Japanese smoking cessation therapy (SCT), which consists of smoking cessation intervention five times with nurses' counseling over a 12-week period. Among them, we compared 77 HIV-positive male individuals and 323 HIV-negative male individuals with complications.

RESULTS

Smokers with HIV had a larger number of cigarettes smoked per day, and higher scores of nicotine dependence and depression compared with the HIV-negative group. The HIV-positive group had a significantly lower success rate of quitting smoking than the HIV-negative group (35.1 vs. 47.7%, p = .046). The subjects living with HIV who had higher self-efficacy showed a significantly higher quit rate compared with those who had lower self-efficacy (odds ratio 9.99, p < .01).

CONCLUSION

Smokers with HIV had characteristics that made it difficult for them to quit smoking. Increasing their self-efficacy of quitting smoking through nurses' counseling will lead to success of quitting smoking in HIV-positive smokers receiving the SCT.

Psychological distress and responses to comparative risk messages about electronic and combusted cigarettes

BACKGROUND

People with mental illness suffer disproportionately high health burdens of smoking. Communicating to these smokers that electronic cigarettes (e-cigarettes) are a less harmful alternative to combusted cigarettes might help them reduce their health risks by encouraging complete switching to e-cigarettes. However, such messages might also cause unintended consequences (e.g., dual use of both combusted and e-cigarettes). Our study examined how smokers with vs. without serious psychological distress (SPD) responded to messages communicating reduced harm of e-cigarettes in relation to cigarettes.

METHOD

In an online experiment, 1400 U.S. adult smokers with and without SPD viewed 1 of 6 messages about reduced harm of e-cigarettes compared to cigarettes or a control message. Then participants reported e-cigarette- and cigarette-related beliefs, and behavioral intentions.

RESULTS

Message type (comparative risk messages vs. control) did not interact with SPD status to produce differential impacts on smokers with and without SPD. Regardless of being exposed to a comparative risk message or a control message, smokers with SPD reported greater perceived absolute risk of e-cigarettes and cigarettes, greater support for tobacco control, greater intentions to switch to e-cigarettes completely and seek help with quitting, and were less likely to report e-cigarettes were less harmful than cigarettes compared to smokers without SPD.

DISCUSSION

Smokers with SPD had greater intentions to switch to e-cigarettes completely and seek help quitting compared to smokers without SPD, which indicates that smokers with SPD may be optimistic about e-cigarettes to help them quit smoking.

Patient perspectives on how living with a mental illness affects making and maintaining healthy lifestyle changes

OBJECTIVE

To understand the ways that mental health symptoms interfere with achieving health goals.

METHODS

Individuals with mental illness diagnoses and varying levels of preventive service use were recruited from federally qualified health centers and an integrated health care delivery system and interviewed. Thematic analysis was used to characterize descriptions of how mental illness experiences influenced lifestyle change efforts.

RESULTS

Three themes described patients' (n = 163) perspectives on barriers to making healthy lifestyle changes: 1) Thinking about making lifestyle changes is overwhelming for individuals already managing the burdens of mental illnesses; 2) Depression makes it difficult to care about a healthy future; and 3) When mental illness symptoms are not adequately treated unhealthy behaviors that provide relief are unlikely to be discontinued. Participants also made suggestions for improving health care delivery to facilitate positive behavior change.

CONCLUSION

Patients with mental illnesses need their clinicians to be empathic, help them envision a healthier future, address unmet mental health needs, and provide resources.

PRACTICE IMPLICATIONS

Primary care clinicians should encourage their patients with mental illnesses to make healthy lifestyle changes within the context of a supportive relationship. Lifestyle change can be overwhelming; clinicians should acknowledge progress and provide ongoing tangible support.

Relationship of Anxiety and Depression with Respiratory Symptoms: Comparison between Depressed and Non-Depressed Smokers in Singapore

The rising prevalence of smokers in the community, specifically psychiatric patients, necessitates smoking cessation as an important strategy for reducing the harmful effects of tobacco. This study aims to compare the profiles of depressed and non-depressed smokers and evaluate how psychiatric symptoms influence respiratory symptoms. A cross-sectional survey was administered to 276 non-depressed adult smokers in the community and 69 adult smokers who had been formally diagnosed with depression in the outpatient clinic of a University Hospital in Singapore. Participants were administered questionnaires on smoking attitudes and perceptions, psychiatric symptoms, and respiratory symptoms. Correlations and multiple regression analyses were conducted. The mean age of smokers in the study was 35.32 ± 13.05 years. Smokers in the community and psychiatric samples were largely similar on all of the sociodemographic factors, except that fewer depressed people were employed (χ² = 8.35, p < 0.01). Smokers with depression also reported more attempts to quit smoking (χ² = 7.14, p < 0.05), higher mean depressive, anxiety, and stress symptom (DASS) scores (t = −10.04, p < 0.01), and endorsed more respiratory symptoms than smokers in the community (t = −2.40, p < 0.05). The DASS scores, number of cigarettes smoked daily, years of smoking, general perception of smokers getting heart disease, and presence of lung disease were positively and significantly correlated with respiratory symptoms. On multiple regression, only anxiety symptoms (β = 0.26, p < 0.05) and the presence of lung disease (β = 0.22, p < 0.001) were significantly correlated with respiratory symptoms. Depressed smokers reported greater difficulty in quitting tobacco use, and they perceived more severe respiratory symptoms compared to non-depressed counterparts. Anxiety symptoms were positively associated with the severity of respiratory symptoms. Smoking cessation campaigns need to specifically target psychological symptoms in smokers and focus more psychoeducation on the risk of cardiovascular disease in the middle-aged population.

Renoprotective effect of Spirulina platensis extract against nicotine-induced oxidative stress-mediated inflammation in rats

BACKGROUND

Nicotine is an important factor in the pathogenesis of renal injury in smokers.

PURPOSE

The purpose of the present study was to investigate the renoprotective effect of Spirulina platensis extract (SP) against chronic nicotine administration in rats.

METHODS

Nicotine intoxication was induced with 0.5 mg/kg BW. Rats received 500 mg SP/kg BW by gastric gavage over 4 weeks.

RESULTS

Our data revealed that nicotine induced renal dysfunction manifested by significant abnormal levels of kidney function markers (creatinine and urea) accompanied by increased levels of oxidative stress biomarker (malondialdehyde) and inflammatory markers (nitric oxide, Interleukin-6 and tumor necrosis factor-α) while antioxidant status as glutathione level and glutathione S-transferase activity were found to be decreased significantly as compared with controls. It is worthy to note that nicotine toxicity induced significant increments in the protein expression levels of nuclear factor kappa B as well as caspase-3. Histopathological observations showed tubular necrosis and congestion in the endothelial lining glomerular tuft and epithelial lining renal tubules with nicotine intoxication. Interestingly, our data demonstrated that SP supplementation significantly improved the nicotine-induced kidney dysfunction, alleviated the induced-lipid peroxidation, inflammatory, apoptotic protein markers, and boosted the enzymatic/non-enzymatic antioxidants. Moreover, it attenuated the nicotine-induced histopathological alterations of the kidney architecture.

CONCLUSION

Thus, it is tempting to recommend dietary approaches with Spirulina platensis extract for smokers to minimize the deleterious effect of chronic nicotine consumption and smoke exposure-related problems towards kidney injury via the antioxidant, anti-inflammatory and antiapoptotic properties of Spirulina platensis.

Mental and Addictive Disorders and Medical Comorbidities

PURPOSE OF REVIEW

Mental and addictive disorders commonly co-occur with medical comorbidities, resulting in poor health and functioning, and premature mortality. This review provides an overview of the intertwined causal pathways and shared risk factors that lead to comorbidity. Additionally, this review examines the strategies to prevent the onset of and to effectively manage chronic medical conditions among people with mental and addictive disorders.

RECENT FINDINGS

Recent research provides further evidence for the shared genetic and biological, behavioral, and environmental risk factors for comorbidity. Additionally, there is evidence of effective approaches for screening, self-management, and treatment of medical conditions among people with mental disorders. There are promising health system models of integrated care, but additional research is needed to fully establish their effectiveness. A combination of public health and clinical approaches are needed to better understand and address comorbidity between mental and addictive disorders and chronic medical conditions.