Cigarette smoking and interest in quitting among overweight and obese adults with serious mental illness enrolled in a fitness intervention

Evaluation of a smoking cessation program for adults with severe mental illness in a public mental health service

WHAT IS KNOWN ON THE SUBJECT

Smoking rates have decreased in the general population but remain high among people with severe mental illness (SMI).

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

An individualized smoking cessation program was tested with 99 adults with SMI. The program showed it is possible to help people with SMI smoke fewer cigarettes and reduce nicotine addiction. Customized smoking cessation programs are essential for those with high nicotine dependence and mental health challenges.

IMPLICATIONS FOR PRACTICE

Mental health services should offer tailored tobacco cessation programs because these programs can improve the health of people with mental illness who smoke. It is important for mental health services to follow government guidelines and provide evidence-based support.

ABSTRACT

INTRODUCTION: Despite significant reductions in smoking rates in the general population over recent decades, smoking rates remain relatively unchanged among people with SMI.

AIM

To evaluate the feasibility and preliminary effectiveness of the Keep Quitting in Mind pilot program, an individualized smoking cessation program for people experiencing SMI.

METHODS

In total, 99 adult participants with SMI and engaged with a community mental health service, participated in the intervention. The intervention included motivational interviewing and goal setting, in addition to provision of pharmaceutical aids (including nicotine replacement therapy).

RESULTS

Analysis determined that the Keep Quitting in Mind pilot program was feasible in a public adult mental health service and participation in the program was associated with reductions in the number of cigarettes smoked daily and level of nicotine addiction.

DISCUSSION

This real-world pilot program demonstrated feasibility and potential effectiveness in reducing smoking among adults with mental illness. Aligning with government guidelines, tailored smoking cessation programs are crucial due to high nicotine dependence and mental health complexities.

IMPLICATIONS FOR PRACTICE

Given the high rates of cigarette smoking by people with mental illness and the cardiometabolic health risks associated with this, mental health services should consider adding evidence-based and bespoke tobacco cessation programs as part of core business.

A systematic review of factors associated with sustained smoking abstinence in people experiencing severe mental illness following participation in a smoking intervention

OBJECTIVE

People experiencing severe mental illness report higher rates of tobacco smoking than the general population, while rates of quitting and sustaining abstinence are considerably lower. This systematic review aimed to identify factors associated with sustained abstinence in people experiencing severe mental illness following a smoking intervention.

METHOD

Searches were conducted in PubMed, PsycInfo, Scopus, Embase, Emcare, CINAHL and Cochrane Library from the inception of the e-databases until June 2022. Selection criteria included randomised and non-randomised studies of smoking cessation interventions in which most of the participants were experiencing severe mental illness, and reported a follow-up of 3 months or longer. From an initial 1498 unique retrieved records, 26 references were included detailing 17 smoking cessation intervention studies and 3 relapse prevention intervention studies. Risk of bias was assessed using the RoB2 tool for randomised study designs and the ROBINS-I tool for non-randomised designs.

RESULTS

Participation in smoking interventions was associated with higher odds of abstinence in the medium-term, but not long-term follow-ups. There was insufficient evidence that any other factors impact sustained abstinence. Most studies were considered to have some risk of bias, largely due to insufficient availability of analysis plans.

CONCLUSION

Despite an abundance of studies investigating smoking cessation in smokers experiencing severe mental illness, there is limited knowledge on the factors associated with staying quit. The inclusion of people experiencing severe mental illness in large-scale randomised control trials, in which predictors of sustained abstinence are measured in the medium and long term are needed to address this important question.

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.

Effectiveness of a brief lifestyle intervention targeting mental health staff: analysis of physical fitness and activity in the Keeping Our Staff in Mind study

BACKGROUND

People with mental illness die on average 15 years less than the general population, primarily to cardiometabolic disease. Lifestyle interventions are effective in reducing cardiometabolic risk but are not routinely provided to mental health consumers. Lifestyle interventions targeting mental health staff may be beneficial in changing culture surrounding physical health and subsequently improving consumer outcomes. This study examines exercise and fitness outcomes of a targeted lifestyle intervention directed at Australian mental health staff.

METHODS

A pragmatic single-arm intervention study was conducted within an Australian public mental health service. Mental health staff were provided a five-session individualised lifestyle intervention (incorporating exercise and nutritional counselling) over 5 weeks. Two waves of the programme were delivered between 2015 and 2016. This paper examines the exercise and fitness outcomes of the second wave of the study. Participants were assessed at baseline and at a 16-week follow-up. The primary exercise outcome was a measurement of cardiorespiratory fitness. Secondary outcomes included self-reported physical activity and a measurement of handgrip strength.

RESULTS

A total of 106 staff participated in this component of the study. Cardiorespiratory fitness increased significantly from baseline to follow-up (p<0.001). Significant improvements to physical activity occurred with decreases in sedentary time (p<0.0005) and increases in moderate-to-vigorous physical activity (p<0.005).

CONCLUSION

Lifestyle interventions incorporating exercise counselling may improve the physical health of mental health staff. Such strategies may be effective in improving culture surrounding physical health and/or increasing the effectiveness of lifestyle interventions targeting mental health consumers.

Qualitative analysis of social network influences on quitting smoking among individuals with serious mental illness

Objective: The prevalence of cigarette smoking among adults with serious mental illness (SMI) remains high in the United States despite the availability of effective smoking cessation treatment. Identifying social influences on smoking and smoking cessation may help enhance intervention strategies to help smokers with SMI quit. The objective of this qualitative study was to explore social network influences on efforts to quit smoking among adults with SMI enrolled in a cessation treatment program. Methods: Participants were 41 individuals with SMI enrolled in a Medicaid Demonstration Project of smoking cessation at community mental health centers. A convenience sampling strategy was used to recruit participants for social network interviews exploring the influence of family, friends, peers, and significant others on quitting smoking. A team-based analysis of qualitative data involved descriptive coding, grouping coded data into categories, and identifying themes across the data. Results: Social barriers to quitting smoking included pro-smoking social norms, attitudes, and behaviors of social network members, and negative interactions with network members, either specific to smoking or that triggered smoking. Social facilitators to quitting included quitting with network members, having cessation role models, and social support for quitting from network members. Conclusions: Similar to the general population, social factors appear to influence efforts to quit smoking among individuals with SMI enrolled in cessation treatment. Interventions that leverage positive social influences on smoking cessation have the potential to enhance strategies to help individuals with SMI quit smoking.

Reasons for smoking and barriers to cessation among adults with serious mental illness: A qualitative study

AIMS

Most research into reasons for smoking among adults with serious mental illness (SMI) has focused on reasons related to SMI symptoms. The current study reports reasons for smoking and barriers to cessation that are both related and unrelated to SMI symptoms among adults with SMI.

METHODS

Four focus groups were conducted among current smokers receiving outpatient care for a psychotic disorder in 2017 (N = 24). Participants were asked why they currently smoke and their barriers to quitting smoking.

RESULTS

Smoking as a coping mechanism and to self-medicate SMI symptoms were reasons for current smoking and barriers to cessation. Avoidance of other unhealthy behaviors, routine, and enjoyment emerged as reasons for smoking and barriers to cessation that were unrelated to mental illness.

CONCLUSION

Consideration of factors that are both related and unrelated to SMI symptoms in smoking cessation interventions and brief cessation counseling may improve cessation success in this population.

Feasibility of a support person intervention to promote smoking cessation treatment use among smokers with mental illness

Social support may be an effective strategy to increase engagement in cessation treatment for smokers with mental illness. The purpose of this pilot study was to assess the feasibility of a support person intervention linking smokers with mental illness to an online smoking cessation decision aid. We conducted a 12-week pilot study of a one-session telephone coaching intervention ("Care2Quit") to train nonsmoking family members and friends (i.e., support persons) to promote the use of an online cessation decision aid by smokers with mental illness. The primary aim of the study was to assess the feasibility of the support person intervention by examining recruitment, retention, adherence, and participant satisfaction. A secondary aim was to explore changes in the hypothesized mechanism underlying the intervention effect (i.e., cessation support provided) and primary outcome (i.e., smoker use of online cessation decision aid). Seventeen support persons enrolled, of which 94% (n = 16) completed the telephone coaching intervention. Eighty-eight percent of support persons rated the intervention as highly acceptable. Self-reported cessation supportive behaviors by the support person increased significantly by 6 weeks post intervention. Forty-one percent of smokers (n = 7) linked to support persons used the online cessation decision aid by 12 weeks following the support person's telephone coaching session. Preliminary results from this study demonstrate the feasibility of a support person intervention to promote the use of smoking cessation treatment among smokers with mental illness. Future research to evaluate the efficacy of the Care2Quit support partner intervention is warranted.

Egocentric social networks and smoking among adults with serious mental illness

Evidence-based smoking cessation treatment is safe and effective for smokers with serious mental illness (SMI); however, quit rates remain low in this population. We explored how social networks influence smoking outcomes among people with SMI who participated in smoking cessation treatment at community mental health centers. We conducted egocentric social network interviews with 41 individuals with SMI who participated in a statewide Medicaid demonstration project of smoking cessation treatment. We estimated the proportions of current smokers, former smokers, and never smokers in participants' (i.e., egos') networks and examined support for quitting from alters, defined as family, friends, peers, or significant others. We used logistic regression and mixed-effect logistic regression to explore the relationship between social network variables and ego's smoking status following cessation treatment. Egos reported an average of 5.9 ± 2.2 alters; 52% of alters were current smokers; 18% were former smokers; and 30% never smoked. The majority (57%) of alters helped an ego quit smoking. The presence of former smokers in the network was associated with decreased odds that the ego was smoking post-treatment. Egos whose friends were highly interconnected were less likely to smoke after treatment. Former smokers in the network may be a valuable resource for quitting particularly for vulnerable groups where there is a high prevalence and acceptability of smoking. Our initial findings suggest that a highly interconnected friendship network structure may be beneficial for people with SMI who are trying to quit smoking.

Improving the health of mental health staff through exercise interventions: a systematic review

BACKGROUND

Exercise interventions are efficacious in reducing cardiometabolic risk and improving symptoms in people with severe mental illness, yet evidence guiding the implementation and scalability of such efforts is lacking. Given increasing efforts to address the disparity in physical health outcomes facing people with a mental illness, novel approaches to increasing adoption of effective interventions are required. Exercise interventions targeting mental health staff may improve staff health while also creating more positive attitudes towards the role of lifestyle interventions for people experiencing mental illness.

AIMS

We aimed to determine the feasibility, acceptability and effectiveness of exercise interventions delivered to staff working in mental health services.

METHOD

A systematic review was conducted from database inception, until November 2017. Studies recruiting staff participants to receive an exercise intervention were eligible for inclusion.

RESULTS

Five studies met the inclusion criteria. Physical health interventions for mental health staff were feasible and acceptable with low dropout rates. Reductions in anthropometric measures and work-related stress were reported.

CONCLUSIONS

Limited evidence suggests that exercise interventions targeting mental health staff are feasible and acceptable. Further research is required to determine the efficacy of such interventions and the impact such strategies may have on staff culture and patient outcomes.

y-QUIT: Smoking Prevalence, Engagement, and Effectiveness of an Individualized Smoking Cessation Intervention in Youth With Severe Mental Illness

Introduction: Young people with psychosis are six times more likely to be tobacco smokers than their gender- and age-matched peers. Smoking is a major contributor to the 15-year reduced life expectancy among people experiencing severe mental illness (SMI). There is a lack of evidence-supported interventions for smoking cessation among young people with SMI. Material and Methods: The study comprised two phases and aimed to assess (i) the prevalence of smoking among a community sample of young people with psychotic illness or at high risk of developing psychosis; (ii) the proportion who engaged in the intervention; (iii) the proportion who achieved smoking cessation; and (iv) secondary smoking-related outcomes. In phase one, prevalence of smoking was assessed among young people with psychotic illness or at high risk of developing psychosis attending a community-based youth mental health service between 16/5/2017 and 16/11/2017. In phase two, over a 1-year period, individuals identified as smokers were invited to participate in a 12-week tailored smoking cessation intervention program that included pharmacological treatment, motivational interviewing, and behavioral change techniques. Those unwilling to participate in a full intervention were offered a brief intervention. Participants of the full intervention were assessed at baseline and at week 12 endpoint on: daily cigarettes smoked (self-report), exhaled CO, nicotine dependence, readiness to quit, and confidence to quit. Results: In phase one, smoking prevalence was 48.2% (53 of 110) among clients of the youth mental health service. Smokers were significantly more likely to be male (X ² = 6.41 p = 0.009). During phase two, 41 of 61 eligible clients engaged in a smoking cessation intervention (67.2%). Effectiveness: twenty-one clients participated in a full intervention (34.4%), of whom three (14.3%) received a brief intervention initially and during engagement converted to full intervention. Twenty participants (32.8%) received a brief intervention only. Ten participants in the full intervention (47.6%) and five in the brief intervention (25%) dropped out. Six (28.6% of full intervention) reported smoking cessation verified by CO monitoring. Participants who completed the full intervention (n = 9) reduced number of cigarettes smoked, nicotine dependence, and exhaled CO, while readiness to quit and confidence to quit increased. Pharmacotherapy was predominantly combination NRT (n = 18; 85.7%), varenicline (4.8%), oral NRT only (4.8%), or none (4.8%). No adverse events were reported. Conclusion: This pilot real-world study demonstrates that both screening for smoking and offering an effective smoking cessation intervention are achievable in youth experiencing or at risk of psychosis.

Preferences for Smoking Cessation Support from Family and Friends Among Adults with Serious Mental Illness

Engaging natural supports may be a promising strategy to promote the use of evidence-based smoking cessation treatment for individuals with serious mental illness (SMI) who smoke. This qualitative study explored preferences for support for quitting from family and friends among individuals with SMI who participated in cessation treatment. Participants were 41 individuals with SMI enrolled in a Medicaid Demonstration Project of smoking cessation at community mental health centers. Open-ended questions asked during a social network interview explored participants' preferences for more support for quitting smoking from family and friends. The qualitative data was coded and common themes were identified across the dataset. Three primary preferences emerged for smoking cessation support from family members and friends: 1) more practical support for quitting (e.g., financial help with purchasing cessation medications); 2) more emotional support for quitting (e.g., encouraging progress toward quitting); and 3) changing their own smoking behaviors in the presence of participants (e.g., don't smoke around them or offer them cigarettes). Individuals with SMI who participated in smoking cessation treatment at community mental health centers indicated several ways that family members and friends could support their efforts to quit smoking. Understanding how people with SMI want support from family and friends to quit smoking will inform strategies to leverage these natural resources to promote the use of evidence-based smoking cessation treatment and support smoking abstinence for this population.

An Online Survey of Family Members' Beliefs and Attitudes About Smoking and Mental Illness

OBJECTIVE

Family beliefs about smoking and cessation may influence whether individuals with mental illness who smoke use effective cessation treatment. We surveyed family members online regarding beliefs about smoking and cessation among people with mental illness. Method: Two hundred fifty-six family members of individuals with mental illness completed an online survey. Responses were summarized and t tests were used to compare responses based on the family member's smoking status.

RESULTS

One-quarter of respondents agreed that people with mental illness must smoke to manage mental health symptoms, nearly half (48%) expressed uncertainty about the whether nicotine replacement therapy is harmful for this population, and 69% believed that family members do not have the skills to help an individual with mental illness quit smoking.

CONCLUSIONS

Misconceptions about smoking and mental illness and uncertainty about the safety of cessation treatment may interfere with family support for quitting smoking among people with mental illness.

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

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

Wearable Devices and Smartphones for Activity Tracking Among People with Serious Mental Illness

INTRODUCTION

People with serious mental illness, including schizophrenia spectrum and mood disorders, are more physically inactive than people from the general population. Emerging wearable devices and smartphone applications afford opportunities for promoting physical activity in this group. This exploratory mixed methods study obtained feedback from participants with serious mental illness to assess the acceptability of using wearable devices and smartphones to support a lifestyle intervention targeting weight loss.

METHODS

Participants with serious mental illness and obesity enrolled in a 6-month lifestyle intervention were given Fitbit activity tracking devices and smartphones to use for the study. Participants completed quantitative post-intervention usability and satisfaction surveys, and provided qualitative feedback regarding acceptability of using these devices and recommendations for improvement through in-depth interviews.

RESULTS

Eleven participants wore Fitbits for an average of 84.7% (SD=18.1%) of the days enrolled in the study (median=93.8% of the days enrolled, interquartile range=83.6-94.3%). Participants were highly satisfied, stating that the devices encouraged them to be more physically active and were useful for self-monitoring physical activity and reaching daily step goals. Some participants experienced challenges using the companion mobile application on the smartphone, and recommended greater technical support, more detailed training, and group tutorials prior to using the devices.

DISCUSSION

Participants' perspectives highlight the feasibility and acceptability of using commercially available mHealth technologies to support health promotion efforts targeting people with serious mental illness. This study offers valuable insights for informing future research to assess the effectiveness of these devices for improving health outcomes in this high-risk group.

Lifestyle Intervention for People With Severe Obesity and Serious Mental Illness

INTRODUCTION

People with serious mental illness experience elevated severe obesity rates, yet limited evidence documents whether lifestyle intervention participation can benefit these individuals. This study examined the impact of the In SHAPE lifestyle intervention on weight loss among participants with serious mental illness and severe obesity (BMI ≥40) compared with participants who are overweight (BMI 25 to <30) and have class I (BMI 30 to <35) or class II (BMI 35 to <40) obesity.

METHODS

Data were combined from three trials of the 12-month In SHAPE intervention for individuals with serious mental illness collected between 2007 and 2013 and analyzed in 2014. In SHAPE includes individual weekly meetings with a fitness trainer, a gym membership, and nutrition education. The primary outcome was weight loss. Secondary outcomes were fitness, blood pressure, lipids, and program adherence.

RESULTS

Participants (N=192) were diagnosed with schizophrenia spectrum (53.1%) or mood (46.9%) disorders. At 12 months, the overall sample showed significant weight loss, but differences among BMI groups were not significant (severe obesity, 2.57% [7.98%]; class II, 2.26% [8.69%]; class I, 1.05% [6.86%]; overweight, 0.83% [7.62%]). One third of participants with severe obesity achieved ≥5% weight loss, which was comparable across groups. More participants with severe obesity achieved ≥10% weight loss (20%) than overweight (2.9%, p=0.001) and class I (5.9%, p<0.001), but not class II (17.8%, p=0.974), obesity groups.

CONCLUSIONS

People with severe obesity and serious mental illness benefit similarly to those in lower BMI groups from lifestyle intervention participation.

A Qualitative Study of Client-Clinician Text Exchanges in a Mobile Health Intervention for Individuals With Psychotic Disorders and Substance Use

OBJECTIVE

Mobile health (mHealth) approaches have the potential to transform prevention, wellness, and illness management for people with dual diagnosis consisting of co-occurring mental illness and substance use disorders by providing timely and cost-effective interventions in clients' natural environments. However, little is known about how clients interact with mHealth interventions to manage their illness. This qualitative study explored the content of mobile phone text messages between clients with dual diagnosis and a clinician who engaged them in daily assessment and intervention text exchanges.

METHODS

Seventeen participants with psychotic disorders and substance use were enrolled in a 12-week single-arm trial of an mHealth intervention focusing on illness management. The clinician (i.e., mobile interventionist) sent daily text messages to participants' privately owned mobile phones to assess their medication adherence and clinical status. The clinician provided other illness management and wellness suggestions flexibly, in response to participants' needs and preferences. In this qualitative study we conducted a thematic analysis of the client-clinician text exchanges that occurred over the course of the intervention.

RESULTS

Seven major content themes in client-clinician text message exchanges were identified: mental health symptoms; mental health coping strategies; mental health treatment and management; lifestyle behaviors; social relationships and leisure activities; motivation and personal goal setting; and independent living. Participants were interested in discussing strategies for coping with mental health symptoms (e.g., cognitive restructuring, social support) and health behavior change (e.g., increased physical activity, dietary changes).

CONCLUSIONS

Our findings suggest that client-centered text messaging has the potential to be an important component of illness management for people with dual diagnosis. This approach is able to offer coping strategies that are tailored to clients' needs and preferences in real time when help is needed.