Efficacy and tolerability of pharmacotherapy for smoking cessation in adults with serious mental illness: a systematic review and network meta-analysis

Tobacco use disorder in patients with other mental disorders: a dual disorder perspective from clinical neuroscience

Tobacco smoking is the leading cause of disability and preventable deaths worldwide, but it should be differentiated from tobacco use disorder, which is, according to the Diagnostic and Statistical Manual of Mental Disorders, a bona fide mental disorder. The rapid delivery of nicotine to the brain activates acetylcholine receptors and stimulates the release of dopamine, both systems implicated in other mental disorders. Rates of tobacco use disorder are much higher among people suffering from other mental disorders and these patients find it more difficult to quit. Dual disorders, from a transdiagnostic perspective, identify patients with substance use disorder, in this case tobacco use disorder, and other mental disorders. A dual disorder is a complex clinical condition that is often underdiagnosed, undertreated, and difficult to manage. Appropriate and integrated tobacco use disorder treatment programs for people also suffering from other mental disorders could improve outcomes. Bio-psycho-social approaches to tobacco use disorder include specific biological treatments (e.g., bupropion, varenicline, cytisine, nicotine replacement therapy or deep trans-magnetic stimulation). However, these treatments don't have the same outcomes in patients with dual disorders. Therefore, as in other dual disorders, harm reduction measures, such as vaping nicotine through electronic cigarettes or tobacco replacement therapies should be considered as alternative tools for dual tobacco use disorder management. These clinical considerations emerge from a narrative literature review and expert consensus and will specifically address considerations for changes in clinical practice to improve the treatment of tobacco use disorder and other mental disorders.

Interventions for smoking cessation in inpatient psychiatry settings

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of smoking cessation interventions on tobacco smoking in adults receiving inpatient psychiatry treatment. To assess whether the effects of smoking cessation interventions differ according to psychiatric diagnosis or type of intervention or comparator condition.

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.

Dying to Quit: Understanding the Burden of Tobacco in Psychiatric Patients-A Clinical Review

Smoking is the leading cause of preventable death worldwide and remains a critical public health challenge. The burden of disease caused by smoking is disproportionately borne by persons living with mental illness. Public health efforts to address smoking have not historically translated to a significant reduction in smoking prevalence among patients with mental illness. Smoking is a substantial cause of morbidity and mortality among psychiatric patients who smoke at 1.7 to 3.3 times the rate of the general population. Among those with serious mental illness, tobacco-related illness accounts for half of all deaths. Nicotine dependence also interferes with treatment and worsens many psychiatric symptoms. Interventions are underutilized due to persistent misunderstandings regarding tobacco cessation for patients who are mentally ill. Addressing these misunderstandings is crucial in targeting the disparate rates of smoking in this population. Therefore, it is incumbent on psychiatrists to address the outsized effect that smoking has on patients with mental illness.

Efficacy and safety of pharmacological intervention for smoking cessation in smokers with diseases: A systematic review and network meta-analysis

OBJECTIVE

To investigate the most effective and best-tolerated drugs for treating diseased smokers.

METHODS

Eight databases were searched for randomized controlled trials (RCTs) involving different pharmacological interventions for smoking cessation in disease patients (January 2023). Network meta-analysis was performed using STATA 15.1 software. The Cochrane Risk of Bias Tool assessed the risk of bias, and confidence in evidence was assessed using CINeMA.

RESULTS

A total of 60 RCTs involving 13,009 patients of 12 disease categories were included. All trials reported 13 interventions, resulting in 78 comparisons. Network meta-analysis showed that varenicline (OR = 2.30, 95% CI (1.77, 3.00)) and bupropion (OR = 1.65, 95% CI (1.29, 2.11)) showed favorable abstinence effects compared to placebo in the cardiovascular disease population. Nicotine replacement therapy (NRT) had better withdrawal advantages than placebo (OR = 11.18, 95% CI (2.25, 55.54)) in the chronic obstructive pulmonary disease (COPD) population. Some combination treatments showed better results than monotherapy, such as bupropion + NRT was superior to bupropion (OR = 8.45, 95% CI (1.84, 38.89)) and NRT (OR = 4.98, 95% CI (1.25, 19.78)) in mental illness population. The final surface under the cumulative ranking curve indicated that bupropion + NRT achieved the best smoking cessation effect. Overall confidence in the evidence was low. In a comparison of drugs, the results showed that bupropion + NRT had the best safety.

CONCLUSIONS

Most interventions show the benefit of quitting smoking compared with placebo, including monotherapy and combination therapy. Moreover, varenicline or bupropion combined with NRT is superior to some monotherapies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

The parent study is registered at www.

CLINICALTRIALS

gov NCT00724308.

Association Between Mental Health Burden, Clinical Presentation, and Outcomes in Individuals With Symptomatic Peripheral Artery Disease: A Scientific Statement From the American Heart Association

Along with the rising burden of peripheral artery disease (PAD), mental health concerns are increasingly being recognized as a comorbidity to address in the chronic disease management of symptomatic PAD. Apart from a high prevalence of comorbid mental health conditions, the role of pain and changing health behaviors and the broader impacts of illness and adaptation to living with PAD require specialized behavioral health expertise. This scientific statement builds a case that this expertise should be integrated within the multidisciplinary PAD team. Furthermore, areas such as cognitive dysfunction and palliative care are highlighted as needing psychological interventions. Although much of the evidence of the efficacy of psychological and psychotropic interventions has been extrapolated from other cardiovascular populations, evidence for the role of psychological interventions for behavior change, for example, uptake of exercise regimens, is increasingly being accrued within PAD. Areas for behavioral health needs and interactions with PAD treatment are discussed, including the use of opioids, depression management, anxiety and stress reduction interventions, the use of benzodiazepines and antidepressants, smoking cessation, rehabilitation trajectories after amputation, and the role of cognitive decline for PAD treatment and outcomes. A case summary highlights the stigma around mental health and vascular disease and the fragmentation of care. This scientific statement provides remarks for building a road map for integrated behavioral PAD care and potential solutions to overcome these barriers. Instrumental to reaching these changes are interprofessional advocacy efforts and initiatives that help break down the stigma around mental health and promote evidence-based collaborative, nonhierarchical, and multidisciplinary PAD care.

The Effectiveness of a Telephone Smoking Cessation Program in Mental Health Clinic Patients by Level of Mental Well-Being and Functioning: A Secondary Data Analysis of a Randomized Clinical Trial

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

The parent study is registered at www.clinicaltrials.govNCT00724308.

Efficacy and safety of antidepressants for smoking cessation: A systematic review and network meta-analysis

To evaluate the effectiveness, safety and tolerability of antidepressants in helping smokers quit tobacco dependence, five databases were searched for randomized controlled trials (RCTS ) on different antidepressant interventions involving smoking cessation in populations (September 2022). The STATA 15.1 software was used to perform network meta-analysis. The Cochrane bias risk tool was used to assess the risk of bias, and CINeMA was used to evaluate the evidence credibility for the effect of different interventions on smoking cessation. In all, 107 RCTs involving 42 744 patients were included. Seven studies were rated as having a low risk of bias. All trials reported 18 interventions and 153 pairwise comparisons were generated. The network meta-analysis showed that compared with placebo, varenicline + bupropion (OR = 3.53, 95% CI [2.34, 5.34]), selegiline + nicotine replacement therapy (NRT) (OR = 3.78, 95% CI [1.20, 11.92]), nortriptyline + NRT (OR = 2.33, 95% CI [1.21, 4.47), nortriptyline (OR = 1.58, 95% CI [1.11,2.26]), naltrexone + bupropion (OR = 3.84, 95% CI [1.39, 10.61]), bupropion + NRT (OR = 2.29, 95% CI [1.87, 2.81]) and bupropion (OR = 1.70, 95% CI [1.53, 1.89]) showed benefits with respect to smoking cessation. In addition, bupropion + NRT showed better effects than bupropion (OR = 1.35, 95% CI [1.12, 1.64]) and NRT (OR = 1.38, 95% CI [1.13, 1.69]) alone. The final cumulative ranking curve showed that varenicline + bupropion was the most likely to be the best intervention. There was moderate- to very-low-certainty evidence that most interventions showed benefits for smoking cessation compared with placebo, including monotherapy and combination therapies. Varenicline + bupropion had a higher probability of being the best intervention for smoking cessation.

IMPACT smoking cessation support for people with severe mental illness in South Asia (IMPACT 4S): A protocol for a randomised controlled feasibility trial of a combined behavioural and pharmacological support intervention

INTRODUCTION

The prevalence of smoking is high among people living with severe mental illness (SMI). Evidence on feasibility, acceptability and effectiveness of smoking cessation interventions among smokers with SMI is lacking, particularly in low- and middle-income countries. We aim to test the feasibility and acceptability of delivering an evidence-based intervention,i.e., the IMPACT smoking cessation support for people with severe mental illness in South Asia (IMPACT 4S) intervention that is a combination of behavioural support and smoking cessation pharmacotherapies among adult smokers with SMI in India and Pakistan. We will also test the feasibility and acceptability of evaluating the intervention in a randomised controlled trial.

METHODS

We will conduct a parallel, open label, randomised controlled feasibility trial among 172 (86 in each country) adult smokers with SMI in India and Pakistan. Participants will be allocated 1:1 to either Brief Advice (BA) or the IMPACT 4S intervention. BA comprises a single five-minute BA session on stopping smoking. The IMPACT 4S intervention comprises behavioural support delivered in upto 15 one-to-one, face-to-face or audio/video, counselling sessions, with each session lasting between 15 and 40 minutes; nicotine gum and/or bupropion; and breath carbon monoxide monitoring and feedback. Outcomes are recruitment rates, reasons for ineligibility/non-participation/non-consent of participants, length of time required to achieve required sample size, retention in study and treatments, intervention fidelity during delivery, smoking cessation pharmacotherapy adherence and data completeness. We will also conduct a process evaluation.

RESULTS

Study will address- uncertainty about feasibility and acceptability of delivering smoking cessation interventions, and ability to conduct smoking cessation trials, among adult smokers with SMI in low- and middle-income countries.

CONCLUSIONS

This is to inform further intervention adaptation, and the design and conduct of future randomised controlled trials on this topic. Results will be disseminated through peer-review articles, presentations at national, international conferences and policy-engagement forums.

TRIAL REGISTRATION

ISRCTN34399445 (Updated 22/03/2021), ISRCTN Registry https://www.isrctn.com/.

Smoking Cessation Medication Prescribing for Smokers With and Without Mental Illness

OBJECTIVE

This study examined trends in receipt of smoking cessation medications among smokers with and without mental illness, including serious mental illness, from 2005 to 2019 and characterized physician attitudes and practices related to tobacco screening and cessation treatment.

METHODS

Medical Expenditure Panel Survey (MEPS) data (2005-2019) were examined for receipt of cessation medication prescriptions for bupropion, varenicline, and nicotine replacement therapy (NRT) among 55,662 smokers-18,353 with any mental illness and 7,421 with serious mental illness. Qualitative interviews with 40 general internists and psychiatrists between October and November 2017 used a semistructured guide. MEPS data were analyzed with descriptive statistics, and interviews were analyzed with hybrid inductive-deductive coding.

RESULTS

From 2005 to 2019, at least 83% of smokers with or without mental illness did not receive varenicline, NRT, or bupropion. Over 14 years, the proportion of smokers receiving varenicline peaked at 2.1% among those with no mental illness, 2.9% among those with any mental illness, and 2.4% among those with serious mental illness. The respective peak proportions for NRT were 0.4%, 1.1%, and 1.6%; for bupropion, they were 1.2%, 8.4%, and 16.7%. Qualitative themes were consistent across general internists and psychiatrists; providers viewed cessation treatment as challenging because of the perception of smoking as a coping mechanism and agreed on barriers to treatment, including lack of insurance coverage and contraindications for people with mental illness.

CONCLUSIONS

System- and provider-level strategies to support evidence-based smoking cessation treatment for people with and without mental illness are needed.

F, Deng X, Wang Y, Wang Z, Wu Y, Xu M, Yang C, Li X, Yang K. Pharmacological interventions on smoking cessation: A systematic review and network meta-analysis

Objective: A network meta-analysis based on randomized controlled trials was conducted to investigate the effects of pharmacological interventions on smoking cessation.

Methods: English databases were searched to obtain randomized controlled trials reporting the effect of pharmacological interventions on smoking cessation. The risk of bias for the included trials was assessed using Cochrane Handbook tool. Stata 15.1 software was used to perform network meta-analysis, and GRADE approach was used to assess the evidence credibility on the effects of different interventions on smoking cessation.

Results: A total of 159 studies involving 60,285 smokers were included in the network meta-analysis. The analysis involved 15 interventions and which yielded 105 pairs of comparisons. Network meta-analysis showed that varenicline was more helpful for smoking cessation than other monotherapies, such as nicotine replacement therapy [Odds Ratio (OR) = 1.42, 95% confidence interval (CI) (1.16, 1.73)] and bupropion [OR = 1.52, 95% CI (1.22, 1.89)]. Furthermore, combined interventions were superior to monotherapy in achieving smoking cessation, such as varenicline plus bupropion over bupropion [OR = 2.00, 95% CI (1.11, 3.61)], varenicline plus nicotine replacement therapy over nicotine replacement therapy [OR = 1.84, 95% CI (1.07, 3.18)], and nicotine replacement therapy plus mecamylamine over naltrexone [OR = 6.29, 95% CI (1.59, 24.90)]. Finally, the surface under the cumulative ranking curve value indicated that nicotine replacement therapy plus mecamylamine had the greatest probability of becoming the best intervention.

Conclusion: Most pharmacological interventions demonstrated a benefit in smoking cessation compared with placebo, whether monotherapy or combination therapy. Moreover, confirmed evidence suggested that some combination treatments, such as varenicline plus bupropion and nicotine replacement therapy plus mecamylamine have a higher probability of being the best smoking cessation in

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.

A systematic review of behavioural smoking cessation interventions for people with severe mental ill health-what works?

BACKGROUND AND AIMS

People with severe mental ill health smoke more and suffer greater smoking-related morbidity and mortality. Little is known about the effectiveness of behavioural interventions for smoking cessation in this group. This review evaluated randomized controlled trial evidence to measure the effectiveness of behavioural smoking cessation interventions (both digital and non-digital) in people with severe mental ill health.

DESIGN

Systematic review and random-effects meta-analysis. We searched between inception and January 2020 in Medline, EMBASE, PsycINFO, CINAHL, Health Management Information Consortium and CENTRAL databases.

SETTING AND PARTICIPANTS

Randomized controlled trials (RCTs) assessing the effects of behavioural smoking cessation and reduction interventions in adults with severe mental ill health, conducted in any country, in either in-patient or community settings and published in English.

MEASUREMENTS

The primary outcome was biochemically verified smoking cessation. Smoking reduction and changes in mental health symptoms and body mass index (BMI) were included as secondary outcomes. Narrative data synthesis and meta-analysis were conducted and the quality of included studies was appraised using the risk of bias 2 (RoB2) tool.

FINDINGS

We included 12 individual studies (16 articles) involving 1861 participants. The first meta-analysis (three studies, 921 participants) demonstrated effectiveness of bespoke face-to-face interventions compared with usual care across all time-points [medium-term: relative risk (RR) = 2.29, 95% confidence interval (CI) = 1.38-3.81; long-term: RR = 1.58, 95% CI = 1.09-2.30]. The second (three studies, 275 participants) did not demonstrate any difference in effectiveness of bespoke digital on-line interventions compared with standard digital on-line interventions (medium-term: RR = 0.87, 95% CI = 0.17-4.46). A narrative overview revealed mixed results when comparing bespoke face-to-face interventions with other active interventions. The methodological quality of studies was mixed, with the majority having some concerns mainly around risk of selective reporting.

CONCLUSIONS

Face-to-face bespoke smoking cessation interventions for adults with severe mental ill health appear to be effective when compared with treatment as usual, but evidence is equivocal when compared with other active interventions. There is limited evidence comparing bespoke digital interventions with generic interventions, and we found no studies comparing them with usual treatment.

An evaluation of junior doctors' experience in smoking cessation training in a rural mental health setting

INTRODUCTION

Smoking prevalence remains high amongst people with mental illness, however, they are less likely to be screened for tobacco dependence and offered treatment to quit. Smoking cessation and education training are insufficient in medical schools, despite a positive relationship between training and practice once qualified. However, the question as to whether there is adequate skill and expertise to address smoking in people with mental illness within Australian mental health settings is unclear. Furthermore, people living in rural and remote areas smoke at higher rates, quit at lower rates than those in urban areas, and experience limitations in their ability to access smoking cessation supports. The Smokers' Clinic is an initiative established in a rural Australian mental health service offering a smoking cessation service to patients and staff employed by the service.

AIM

This study aims to assess the change in the knowledge and confidence of resident medical officers in their understanding of nicotine dependence, smoking cessation strategies and prescribing nicotine replacement therapy in a community mental health setting. It was hypothesized that providing education and supervised clinical experience would improve knowledge, increasing confidence and motivation in managing smoking cessation in mental health patients. The research was undertaken using data collected through a questionnaire obtained from surveying resident medical officers administering the Smokers' Clinic following a 10-week rural community mental health rotation.

MATERIALS AND METHODS

Twenty resident medical officers completed the 10-week rotation, with 14 completing the questionnaire. Knowledge of tobacco smoking, nicotine dependence and smoking cessation interventions improved with the experience of the Smokers' Clinic during the clinical rotation. Resident medical officers were motivated to spend additional time engaged in self-directed learning and all reported continued use of acquired experience and information in their clinical work after the rotation.

CONCLUSION

This study indicates the utility of a novel approach in delivering education, training, building clinical expertise, and facilitating sustained clinical capacity amongst junior medical staff for smoking cessation in a rural community mental health setting. It offers an efficient approach for mental health services to deliver smoking cessation services to reduce the morbidity and mortality burden associated with tobacco smoking.

The value of compassionate support to address smoking: A qualitative study with people who experience severe mental illness

INTRODUCTION

People experiencing severe mental illness (SMI) smoke at much higher rates than the general population and require additional support. Engagement with existing evidence-based interventions such as quitlines and nicotine replacement therapy (NRT) may be improved by mental health peer worker involvement and tailored support. This paper reports on a qualitative study nested within a peer researcher-facilitated tobacco treatment trial that included brief advice plus, for those in the intervention group, tailored quitline callback counseling and combination NRT. It contextualizes participant life experience and reflection on trial participation and offers insights for future interventions.

METHODS

Qualitative semi-structured interviews were conducted with 29 participants in a randomized controlled trial (intervention group n = 15, control group n = 14) following their 2-month (post-recruitment) follow-up assessments, which marked the end of the "Quitlink" intervention for those in the intervention group. Interviews explored the experience of getting help to address smoking (before and during the trial), perceptions of main trial components including assistance from peer researchers and tailored quitline counseling, the role of NRT, and other support received. A general inductive approach to analysis was applied.

RESULTS

We identified four main themes: (1) the long and complex journey of quitting smoking in the context of disrupted lives; (2) factors affecting quitting (desire to quit, psychological and social barriers, and facilitators and reasons for quitting); (3) the perceived benefits of a tailored approach for people with mental ill-health including the invitation to quit and practical resources; and (4) the importance of compassionate delivery of support, beginning with the peer researchers and extended by quitline counselors for intervention participants. Subthemes were identified within each of these overarching main themes.

DISCUSSION

The findings underscore the enormity of the challenges that our targeted population face and the considerations needed for providing tobacco treatment to people who experience SMI. The data suggest that a tailored tobacco treatment intervention has the potential to assist people on a journey to quitting, and that compassionate support encapsulating a recovery-oriented approach is highly valued.

CLINICAL TRIAL REGISTRATION

The Quitlink trial was registered with ANZCTR (www.anzctr.org.au): ACTRN12619000244101 prior to the accrual of the first participant and updated regularly as per registry guidelines.

Acceptance and Commitment Therapy versus Social Support for Smoking Cessation for People with Schizophrenia: A Randomised Controlled Trial

Smoking is prevalent among people with schizophrenia. It has been found that Acceptance and commitment therapy (ACT) is effective for treating psychotic symptoms and addictive behaviours, but the therapy has not been modified to help individuals with schizophrenia to quit smoking. A randomised controlled trial was conducted with the objective of comparing a 10-week, individual, face-to-face ACT programme (n = 65) to a social support programme on smoking cessation, experiential avoidance, and emotion-regulation strategies among people with schizophrenia who smoke (n = 65). The primary outcome was self-reported smoking abstinence for 7 days at 6 months after the start of the intervention. Secondary outcomes were self-reported and biochemically validated quit rates post-intervention. The Avoidance and Inflexibility Scale (AIS), Acceptance and Action Questionnaire II (AAQII), and Emotion Regulation Questionnaire (ERQ) were employed. The self-reported quit rates in the ACT group were higher than in the social support group, although no significant differences were found (6 months: 12.3% vs. 7.7%, p = 0.56, 12 months: 10.8% vs. 7.7%, p = 0.76). We found significantly greater improvements in smoking-specific and ACT-specific experiential avoidance and less reliance on emotion regulation strategies in the ACT group at some time points. Overall, ACT is better than social support at enhancing experiential avoidance and reducing reliance on emotion regulation strategies in adults with schizophrenia who smoke. However, ACT did not produce a much better result than social support in helping them to completely quit smoking.

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.

Quitline Programs Tailored for Mental Health: Initial Outcomes and Feasibility

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.

A qualitative study of the views about smoking, licensed cessation aids and e-cigarettes in people with schizophrenia spectrum disorders

Smoking prevalence remains high among people with a mental health condition compared to those without. Understanding people's motivation to quit and their views of smoking cessation support may help to develop future interventions. We conducted a qualitative study to explore the perceptions of 30 people with schizophrenia spectrum disorders who were current smokers, about smoking traditional cigarettes, the appeal of licensed medicines and e-cigarettes for smoking cessation or smoking reduction. The experiences of participants who were motivated to quit were compared with those who were not motivated to quit. Findings suggest traditional cigarettes were pleasurable and licensed cessation aids and e-cigarettes unappealing to participants who were unmotivated to quit. Whereas nicotine replacement products and e-cigarettes may be an appealing smoking cessation or reduction strategy for those motivated to quit. There is a need to find ways of making traditional cigarettes less appealing and alternative less harmful nicotine products (licensed and unlicensed) more appealing and accessible to this group of high risk smokers.

Approved and emerging smoking cessation treatments for people with schizophrenia spectrum disorders: A narrative review

This review focuses on smoking cessation treatments for people with schizophrenia spectrum disorders. It concludes with comments on the significance of the research and why it constitutes an original contribution. We searched PubMed (National Library of Medicine), and PsycINFO (Ovid) (2006-2020) for studies on schizophrenic disorder (schizophrenia or psychotic or psychosis or severe mental illness) and smoking cessation treatment (smoking cessation treatment or varenicline or tobacco cessation or reduction or bupropion or NRT or behavioral treatment or e-cigarette). Studies found evidence suggesting that pharmacotherapy combined with behavioural therapy for smoking cessation is effective amongst smokers with schizophrenia spectrum disorders, although more long-term research is required. This review summarised and critically reviewed also studies on vaping as a smoking cessation strategy for smokers with schizophrenia spectrum disorders and evidence suggests that they may effective as smoking cessation tool and may be less harmful alternatives to combustible cigarette smoking. Consequently, e-cigarettes could be considered as an applicable instrument for Tobacco Harm Reduction (THR) and smoking cessation. Overall, there are very few studies of e-cigarettes for smoking cessation in patients with schizophrenia and these studies are very small. They have promising results, but more research is needed.

Feasibility of a Consumer Centred Tobacco Management intervention in Community Mental Health Services in Australia

This study tested a new program for helping smokers with severe mental illness to reduce their tobacco use, together with determining the feasibility of such research in community mental health settings in Australia. Five Neami National sites trialled a Consumer Centred Tobacco Management program called Kick the Habit (n = 34). The intervention included two weeks of free Nicotine Replacement Therapy (patches only) but participants also used a variety of self-funded delivery types in addition or as an alternative to the subsidised nicotine patch. At the 3-month follow-up, Kick the Habit participants had reduced their number of daily cigarettes, dependency levels and average weekly expenditure on tobacco. Although a larger study is required, Kick the Habit represents a promising intervention for tobacco management in community mental health services. The challenges and lessons learnt for scaling up to a larger trial and integration into business-as-usual practice across multiple sites are discussed.

Pharmacological interventions for smoking cessation among people with schizophrenia spectrum disorders: a systematic review, meta-analysis, and network meta-analysis

BACKGROUND

People with schizophrenia have higher rates of smoking than the general population, and lower quit rates. Several randomised controlled trials have investigated the effectiveness of pharmacological interventions for smoking cessation over the past 20 years. We did a systematic review and pairwise and network meta-analysis of smoking abstinence to guide decision making in offering pharmacological interventions for smoking cessation for people with schizophrenia spectrum disorders.

METHODS

We systematically reviewed PubMed, Embase, Cochrane Central Register of Controlled Trials, PsycINFO, and China National Knowledge Infrastructure from inception to Sept 30, 2019, for randomised controlled trials of varenicline, bupropion, and nicotine replacement therapy for smoking cessation for people with schizophrenia spectrum disorders or psychotic disorders who were smokers at the time of study recruitment. Data were extracted from published studies on smoking abstinence outcomes and psychotic symptoms. We did pairwise and network meta-analyses for the primary outcome of smoking abstinence. Sensitivity analyses were done on study inclusion criteria, duration, quality, and location. This study is registered with the international prospective register of systematic reviews PROSPERO, CRD42018102343.

FINDINGS

A total of 15 111 records were identified by the database searches, and 163 full-text articles were assessed for eligibility. 145 articles were then excluded for several reasons including insufficient data, or abstracts published in later studies, and 18 studies were included in the meta-analysis. In the pairwise meta-analyses, four studies with 394 participants assessed varenicline (RR 3·75, 95% CI 1·96-7·19, p<0·0001; I²=0%), four studies with bupropion and 292 participants (RR 3·40, 95% CI 1·58-7·34, p=0·0002; I²=0%), and three studies with 561 participants assessed nicotine replacement therapy (RR 4·27, 95% CI 1·71-10·65, p=0·0002; I²=0%). All three treatments were deemed superior to placebo. In the network meta-analysis, varenicline was superior to bupropion (RR 2·02, 95% CI 1·04-3·93; p=0·038) but no significant difference was found between varenicline and nicotine replacement therapy, or bupropion and nicotine replacement therapy. No agents were associated with changes in psychiatric symptoms, but varenicline was associated with higher rates of nausea than was placebo.

INTERPRETATION

We found evidence to support use of pharmacological agents for smoking cessation for people with psychosis. Varenicline might be superior to bupropion; however, additional direct testing and combination trials of pharmacological agents for smoking cessation are required to inform clinical decision making for people with psychosis.

FUNDING

None.

Proposed Neuroimmune Roles of Dimethyl Fumarate, Bupropion, S-Adenosylmethionine, and Vitamin D3 in Affording a Chronically Ill Patient Sustained Relief from Inflammation and Major Depression

We had discussed earlier that, after most of the primary author's multiple sclerosis (MS) symptoms were lessened by prior neuroimmune therapies, use of dimethyl fumarate (DMF) gradually subdued his asthma and urticaria symptoms, as well as his MS-related intercostal cramping; and bupropion supplemented with S-adenosylmethionine (SAMe) and vitamin D3 (vit-D3) helped remit major depression (MD). Furthermore, the same cocktail (bupropion plus supplements), along with previously discussed routines (yoga, meditation, physical exercises, and timely use of medications for other illnesses), continued to subdue MD during new difficulties with craniopharyngioma, which caused bitemporal vision loss; sphenoid sinus infections, which caused cranial nerve-VI (CN6) palsy and diplopia; and through their treatments. Impressed by the benefit the four compounds provided, in this manuscript, we focus on explaining current neuroimmune literature proposals on how: (1) DMF impedes inflammation, oxidative stress, and cell death in CNS and peripheral tissues; (2) Bupropion curbs anxiety, MD, and enhances alertness, libido, and moods; (3) SAMe silences oxidative stress and depression by multiple mechanisms; and (4) Vit-D3 helps brain development and functioning and subdues inflammation. we realize that herein we have reviewed proposed mechanisms of remedies we discovered by literature searches and physician assisted auto-experimentation; and our methods might not work with other patients. We present our experiences so readers are heartened to reflect upon their own observations in peer-reviewed forums and make available a wide body of information for the chronically ill and their physicians to benefit from.

Cigarette Smoking Quit Rates Among Persons With Serious Psychological Distress in the United States From 2008 to 2016: Are Mental Health Disparities in Cigarette Use Increasing?

INTRODUCTION

Prior work suggests that the prevalence of cigarette smoking is persistently higher among people with mental health problems, relative to those without. Lower quit rates are one factor that could contribute to higher prevalence of smoking in this group. This study estimated trends in the cigarette quit rates among people with and without past-month serious psychological distress (SPD) from 2008 to 2016 in the United States.

METHODS

Data were drawn from 91 739 adult participants in the 2008-2016 National Survey on Drug Use and Health, a repeated, cross-sectional, national survey. Linear time trends of cigarette quit rates, stratified by past-month SPD, were assessed using logistic regression models with continuous year as the predictor.

RESULTS

Cigarette quit rates among individuals with past-month SPD were lower than among those without SPD every year from 2008 to 2016. Quit rates did not change appreciably among those with past-month SPD (odds ratio = 1.02 [0.99, 1.06]) from 2008 to 2016, whereas quit rates increased among those without past-month SPD (odds ratio = 1.02 [1.01, 1.02]).

CONCLUSIONS

In the United States, quit rates among individuals with past-month SPD are approximately half than quit rates of those without SPD and have not increased over the past decade. This discrepancy in quit rates may be one factor driving increasing disparities in prevalence of smoking among those with versus without mental health problems. Tobacco control efforts require effective and targeted interventions for those with mental health problems.

IMPLICATIONS

Cigarette smoking quit rates have not increased among persons with serious mental health problems over the past decade. This work extends prior findings showing that smoking prevalence is not declining as quickly among persons with serious mental health problems. Findings suggest that diverging trends in quit rates are one possible driver of the persistent disparity in smoking by mental health status. Innovation in both tobacco control and targeted interventions for smokers with mental health problems is urgently needed.

Mental health and smoking cessation-a population survey in England

BACKGROUND

To reduce inequalities between individuals with and without mental health problems, a better understanding is required of triggers and success of quit attempts among the third of smokers with mental health problems. The aim was to assess whether there are differences by mental health status in (i) triggers for quit attempts, (ii) use of evidence-based support (iii) and quit success.

METHODS

Monthly cross-sectional household surveys of representative samples of the adult population in England. In 2016/2017, 40,831 adults were surveyed; 1956 who had attempted to stop smoking cigarettes in the past year were included. Logistic regressions assessed associations between mental health (ever diagnosis, past-year treatment, past-month distress), triggers, support used and quit success, adjusting for sociodemographic and smoking characteristics.

RESULTS

Concern about future health, current health problems and expense of smoking were the most common triggers overall. For respondents with an ever diagnosis, past-year treatment or serious past-month distress, quit attempts were more frequently triggered by current health problems. Non-evidence-based support and e-cigarettes were used most often, and this did not differ by mental health status. Respondents with an ever diagnosis and moderate or serious distress were less likely to have used non-prescription nicotine replacement therapy (NRT). Respondents with past-year treatment or serious distress were more likely to have used prescription medication/behavioural support. Quit success did not differ by mental health status. Compared with non-evidence-based support, non-prescription NRT conferred no benefit. There was some evidence that prescription medication/behavioural support was beneficial (depending on outcome and adjustment, ORs ranged from 1.46, 95% CI 0.92-2.31, to 1.69, 1.01-2.86). E-cigarettes were associated with higher success rates after adjustment for different indicators of mental health (ORs ranged from 2.21, 1.64-2.98, to 2.25, 1.59-3.18).

CONCLUSIONS

Smokers with mental health problems were more likely to have attempted to quit because of health problems and were more likely to have used gold standard support (medication and behavioural support) than other smokers. E-cigarettes were strongly associated with increased success and were used similarly by those with and without mental health problems, indicating that improved uptake of e-cigarettes for smoking cessation among smokers with mental health problems could help address inequalities.

Tobacco smoking, related harm and motivation to quit smoking in people with schizophrenia spectrum disorders

This narrative review focuses on the topic of tobacco smoking amongst people with schizophrenia spectrum disorders. We searched PubMed, PsycInfo and Scopus databases for schizophrenia spectrum disorders and smoking and included articles about the epidemiology of tobacco smoking in people with schizophrenia spectrum disorders, examining the relationship between smoking and mental health. This narrative review describes that a higher prevalence, frequency and impact of both high nicotine dependence and its harmful effects in patients with schizophrenia spectrum disorders compared with those in the general population. Despite several existent theories, the reasons for high smoking rates, the high dependence on nicotine and severity of nicotine withdrawal symptoms are not fully understood. The main aim of this paper is to inform mental health personnel and particularly clinical and health psychologists about the impact and role of tobacco smoking for smokers with schizophrenia spectrum disorders.

Gaps and challenges: WHO treatment recommendations for tobacco cessation and management of substance use disorders in people with severe mental illness

BACKGROUND

People with severe mental disorders (SMD) experience premature mortality mostly from preventable physical causes. The World Health Organization (WHO) have recently produced guidelines on the management of physical health conditions in SMD. This paper presents the evidence which led to the recommendations for tobacco cessation and management of substance use disorders in SMD.

METHODS

Scoping reviews informed 2 PICO (Population Intervention, Comparator, Outcome) questions relating to tobacco cessation and management of substance use disorders in SMD. Systematic searches led to the identification of systematic reviews with relevant evidence to address these questions. Retrieved evidence was assessed using GRADE methodology, informing the development of guidelines.

RESULTS

One thousand four hundred thirty-four records were identified through systematic searches for SMD and tobacco cessation, of which 4 reviews were included in GRADE tables and 18 reviews in narrative synthesis. For SMD and substance use disorders, 4268 records were identified, of which 4 studies from reviews were included in GRADE tables and 16 studies in narrative synthesis. People with SMD who use tobacco should be offered combined pharmacological (Varenicline, Bupropion or Nicotine Replacement Therapy) and non-pharmacological interventions such as tailored directive and supportive behavioural interventions. For people with SMD and substance use disorders (drug and/or alcohol), interventions should be considered in accordance with WHO mhGAP guidelines. Prescribers should note potential drug-drug interactions. Recommendation were conditional and based on low/very low certainty of evidence with a scarcity of evidence from low- and middle-income settings.

CONCLUSIONS

These guidelines mark an important step towards addressing premature mortality in people with SMD. The dearth of high-quality evidence and evidence from LMIC settings must inform the future research agenda.

GUIDELINES

https://www.who.int/mental_health/evidence/guidelines_physical_health_and_severe_mental_disorders/en https://www.who.int/publications-detail/mhgap-intervention-guide%2D%2D-version-2.0.

A Narrative Review of Intensive Group Tobacco Treatment: Clinical, Research, and US Policy Recommendations

INTRODUCTION

Clinical practice guidelines recommend comprehensive treatment for tobacco dependence including pharmacotherapies and behavioral interventions. Group counseling may deliver unique treatment aspects not available with other modalities. This manuscript provides a narrative review of group treatment outcomes from real-world practice settings and complements recent meta-analyses of randomized controlled trials (RCTs). Our primary goals were to determine whether group treatments delivered in these settings have yielded similar quit rates compared to individual treatment and to provide recommendations for best practices and policy.

METHODS

Group treatment was defined as occurring in a clinical or workplace setting (ie, not provided as part of a research study), led by a professionally trained clinician, and offered weekly over several weeks. English language PubMed articles from January 2000 to July 2017 were searched to identify studies that included outcomes from both group and individual treatment offered in real-world settings. Additional data sources meeting our criteria were also included. Reports not using pharmacotherapy and research studies (eg, RCTs) were excluded. The primary outcome was short-term, carbon monoxide (CO)-validated point prevalence abstinence (4-week postquit date).

RESULTS

The review included data from 11 observational studies. In all cases, group treatment(s) had higher 4-week CO-validated quit rates (range: 35.5%-67.3%) than individual treatment(s) (range: 18.6%-53.3%).

CONCLUSIONS

Best practice group treatments for tobacco dependence are generalizable from research to clinical settings and likely to be at least as effective as intensive individual treatment. The added advantages of efficiency and cost-effectiveness can be significant. Group treatment is feasible in various settings with good results.

IMPLICATIONS

A major barrier to achieving high rates of tobacco abstinence is under-utilization of evidence-based treatment interventions. This review demonstrates the effectiveness and utility of group treatment for tobacco dependence. Based on the available data described in this narrative review in conjunction with existing RCT data, group treatment for tobacco dependence should be established and available in all behavioral health and medical settings. Group tobacco treatment is now one of the mandated reimbursable tobacco treatment formats within the US health care system, creating enormous opportunities for widespread clinical reach. Finally, comprehensive worksite group programs can further extend impact.

Varenicline: mode of action, efficacy, safety and accumulated experience salient for clinical populations

Objective: Varenicline, a selective partial agonist of the α4β2 nicotinic acetylcholine receptor, is a smoking cessation pharmacotherapy that more than doubles the chance of quitting smoking at 6 months compared with placebo. This article reviews salient knowledge of the discovery, pharmacological characteristics, and the efficacy and safety of varenicline in general and in specific populations of smokers and provides recommendations to support use in clinical practice.Methods: Literature searches for varenicline were conducted using PubMed, with date limitations of 2000-2018 inclusive, using search terms covering the discovery, mechanism of action, pharmacokinetics, efficacy and safety in different populations of smokers, alternative quit approaches and combination therapy. Selection of safety and efficacy data was limited to clinical trials, meta-analyses and observational studies.Results: Standard administration of varenicline is efficacious in helping smokers to quit, including smokers with cardiovascular disease and chronic obstructive pulmonary disease. Furthermore, varenicline efficacy may be improved with pre-loading, a gradual quitting approach for smokers unwilling or unable to quit abruptly, and extended treatment in smokers who have recently quit to help maintain abstinence. Initial concerns regarding the association of varenicline with increased risk of neuropsychiatric and cardiovascular adverse events have been disproven after extensive clinical evaluations, and the benefit-risk profile of varenicline is considered favorable.Conclusions: Varenicline is efficacious and safe for all adult smokers with a range of clinical characteristics. Evidence suggests that approaches offering greater flexibility in timing and duration of treatment may further extend treatment efficacy and clinical reach.

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.

Smoking cessation treatment outcomes among people with and without mental and substance use disorders: An observational real-world study

Background:

There is a lack of studies evaluating smoking cessation treatment protocols which include people with and without mental and substance use disorders (MSUD), and which allows for individuals with MSUD undergoing their psychiatric treatment.

Methods:

We compared treatment success between participants with (n = 277) and without (n = 419) MSUD among patients in a 6-week treatment provided by a Brazilian Psychosocial Care Center (CAPS) from 2007 to 2013. Sociodemographic, medical and tobacco use characteristics were assessed at baseline. Tobacco treatment consisted of 1) group cognitive behavior therapy, which included people with and without MSUD in the same groups, and 2) pharmacotherapy, which could include either nicotine patches, nicotine gum, bupropion or nortriptyline. For participants with MSUD, tobacco treatment was integrated into their ongoing mental health treatment. The main outcome was 30-day point prevalence abstinence, measured at last day of treatment.

Results:

Abstinence rates did not differ significantly between participants with and without MSUD (31.1% and 34.4%, respectively). Variables that were significantly associated with treatment success included years smoking, the Heaviness of Smoking Index, and use of nicotine patch or bupropion.

Conclusions:

The inclusion of individuals with and without MSUD in the same protocol, allowing for individuals with MSUD undergoing their psychiatric treatment, generates at least comparable success rates between the groups. Predictors of treatment success were similar to those found in the general population. Facilities that treat patients with MSUD should treat tobacco use in order to reduce the disparities in morbidity and mortality experienced by this population.

Evidence-based guidelines for the pharmacological treatment of schizophrenia: Updated recommendations from the British Association for Psychopharmacology

These updated guidelines from the British Association for Psychopharmacology replace the original version published in 2011. They address the scope and targets of pharmacological treatment for schizophrenia. A consensus meeting was held in 2017, involving experts in schizophrenia and its treatment. They were asked to review key areas and consider the strength of the evidence on the risk-benefit balance of pharmacological interventions and the clinical implications, with an emphasis on meta-analyses, systematic reviews and randomised controlled trials where available, plus updates on current clinical practice. The guidelines cover the pharmacological management and treatment of schizophrenia across the various stages of the illness, including first-episode, relapse prevention, and illness that has proved refractory to standard treatment. It is hoped that the practice recommendations presented will support clinical decision making for practitioners, serve as a source of information for patients and carers, and inform quality improvement.

Nicotine consumption during the prodromal phase of schizophrenia - a review of the literature

Recent research has fueled a debate concerning the role of nicotine in the emergence of schizophrenia. The three main hypotheses are: (a) the self-medication effect, (b) the causal relationship hypothesis, or (c) the shared diathesis hypothesis. To explore this role, the study of nicotine consumption during the initial prodromal phase of schizophrenia offers important opportunities. In the present work, 10 relevant studies are reviewed, out of 727 retrieved citations, in order to address questions regarding the prevalence of smoking in the prodromal period, the time of smoking initiation, existing patterns of tobacco use in relation with the escalation of prodromal symptoms into first psychotic episode, and potential differences in symptomatology between smokers and nonsmokers. Even though there was considerable heterogeneity among studies, relevant findings are discussed. Prevalence of nicotine use during the prodromal period was reported to be 16.6-46%. Tobacco use was found to be taken up most often before or during the prodromal period of schizophrenia. Even though a protective role of smoking has been reported by one study, other studies report an increased risk for psychosis, with hazard ratios 2.77 (95% CI: 2.34-3.43) and 2.21 (95% CI: 1.11-4.42) for female and male heavy smokers (11-20 and >20 cigarettes/day), respectively. In a different study, the risk of onset was associated with the progressive use of cannabis and tobacco prior to onset, particularly with rapid escalation to the highest levels of use. Also, nicotine use in ultra high risk (UHR) for developing psychosis subjects is associated with elevated cognitive performance, namely better processing speed, visual learning, and spatial working memory. As a conclusion, it appears that evidence accumulates supporting a possible etiologic role of smoking, in the emergence of schizophrenia along with diverse effects on patients' symptomatology, already demonstrable at the prodromal phase. Future research employing better-defined criteria should further explore the patterns of use and effects of nicotine during the schizophrenia prodrome.

Which Types of Tobacco Treatment Interventions Work for People with Schizophrenia? Provider and Mental Health Consumer Perspectives

People with schizophrenia and other psychotic disorders (PWS) consume tobacco at high rates, resulting in disproportionate tobacco-related morbidity and mortality. Conventional tobacco treatment (TT) approaches may not adequately address unique affective, cognitive, and social challenges of PWS during cessation. This study sought to obtain provider and mental health consumer perspectives on effective, desirable, applicable, and acceptable components of TT for PWS. This convergent mixed-method study used structured interviews and a cross-sectional survey to obtain data. Eighteen mental health consumers and six mental health providers were engaged in face-to-face or telephone interviews. The qualitative data were analyzed using content analysis and theme identification and descriptive statistics were used for the analysis of quantitative data. In the qualitative analysis, consumers endorsed education, counseling, social support, and pharmacotherapy as key TT components. Consumers further stressed the need for flexible interventions that are available at any point in a quit attempt. Both providers and consumers endorsed targeting TT interventions to consider learning needs, potential cognitive issues, and motivation for behavioral change. Providers encouraged a recovery-driven TT framework with peer support and health promotion activities. Quantitative findings mirrored the qualitative findings with support sessions, relapse prevention, and skills training having the highest desirability, applicability, and acceptability TT component scores. Providers and consumers agreed on components of an effective TT program targeted to PWS. Given these findings, it is crucial to further investigate successful TT approaches for PWS and to test whether targeted or tailored programs are more effective than conventional approaches.

Cigarette Smoking and Quitting-Related Factors Among US Adult Health Center Patients with Serious Mental Illness

INTRODUCTION

US adults with serious mental illness (SMI), compared to those without SMI, have a higher prevalence of smoking, which contributes to a shorter life expectancy. This study compared current smoking and quitting-related characteristics of low-income US adults with and without SMI who received healthcare at federally funded health centers.

METHODS

Using cross-sectional data from adults ≥ 18 years old in the nationally representative 2014 Health Center Patient Survey (n = 5592), we compared the prevalence of ever and current smoking among adults with and without SMI and calculated quit ratios as the percentage of ever smokers who have quit smoking. We examined the association between SMI and receiving advice to quit, making quit attempts, and having plans to quit in the next 30 days using multivariable logistic regression.

RESULTS

A total of 1376 (23%) of participants had SMI. Ever smoking prevalence was 68% in adults with SMI and 41% in adults without SMI, and current smoking prevalence was 48% and 22%, respectively. The quit ratio was 30% and 46% among participants with and without SMI, respectively. Compared to smokers without SMI, more smokers with SMI reported receiving advice to quit in the past 12 months (aOR 2.47, 95% CI 1.20-5.07). Smokers with and without SMI did not differ significantly in their odds of having made a past-12-month quit attempt or plans to quit.

CONCLUSIONS

Smokers with SMI seen in federally funded health centers were just as likely to have made a quit attempt and to have plans to quit as smokers without SMI. Despite a higher likelihood of receiving clinician advice to quit, the lower quit ratio in this population suggests that advice alone is unlikely to be sufficient. These results underscore the need for augmented strategies to promote smoking cessation and reduce the excess burden of tobacco-related disease in patients with SMI.

An evaluation of a pilot specialist smoking cessation clinic in a mental health setting

OBJECTIVES

Smoking rates in people with mental illness in Australia remain alarmingly high whilst they have been declining in the general population. This study reviews a smoking cessation programme in a mental health service, as a pilot for future studies and program development. We aim to assess the effectiveness of this intervention and the ease of implementation after upskilling the clinical workforce.

METHODS

Part A - a retrospective analysis of patients attending the Smokers' Clinic, (n = 44) over a period of 18 months. Part B - survey of ease of implementation and change in practice of the resident medical officers (RMOs; n = 8) following their clinical placement.

RESULTS

For the entire clinic population, the mean reduction in expired carbon monoxide was approximately 43%, with 34% of patients achieving abstinence. Females were 3.4 times more likely to be successful than males. Seventy-five per cent of RMOs found learning about nicotine dependence and smoking cessation 'easy', and 88% continued to offer smoking cessation after their placement.

CONCLUSIONS

The Smokers' Clinic was successful in helping tobacco smokers with mental illness to reduce or cease smoking. Specialist skill and experience is not required to manage smoking cessation in a mental health setting.

Aubin L, Maravic MC, Anthenelli RM. Neuropsychiatric Safety and Efficacy of Varenicline, Bupropion, and Nicotine Patch in Smokers With Psychotic, Anxiety, and Mood Disorders in the EAGLES Trial

BACKGROUND

Neuropsychiatric safety and relative efficacy of varenicline, bupropion, and transdermal nicotine patch (NRT) in those with psychiatric disorders are of interest.

METHODS

We performed secondary analyses of safety and efficacy outcomes by psychiatric diagnosis in EAGLES (Evaluating Adverse Events in a Global Smoking Cessation Study), a 12-week, randomized, double-blind, triple-dummy, placebo- and active (NRT)-controlled trial of varenicline and bupropion with 12-week follow-up, in a subset population, n = 4092, with a primary psychotic (n = 390), anxiety (n = 792), or mood (n = 2910) disorder. Primary end-point parameters were incidence of prespecified moderate and severe neuropsychiatric adverse events (NPSAEs) and weeks 9 to 12 continuous abstinence rates (9-12CAR).

RESULTS

The observed NPSAE incidence across treatments was 5.1% to 6.3% in those with a psychotic disorder, 4.6% to 8.0% in those with an anxiety disorder, and 4.6% to 6.8% in those with a mood disorder. Neither varenicline nor bupropion was associated with significantly increased NPSAEs relative to NRT or placebo in the psychiatric cohort or any psychiatric diagnostic subcohort. There was a significant effect of treatment on 9-12CAR (P < 0.0001) and no significant treatment-by-diagnostic subcohort interaction (P = 0.24). Abstinence rates with varenicline were superior to bupropion, NRT, and placebo, and abstinence with bupropion and NRT was superior to placebo. Within-diagnostic subcohort comparisons of treatment efficacy yielded estimated odds ratios for 9-12CAR versus placebo of greater than 3.00 for varenicline, greater than 1.90 for bupropion, and greater than 1.80 for NRT for all diagnostic groups.

CONCLUSIONS

Varenicline, bupropion, and nicotine patch are well tolerated and effective in adults with psychotic, anxiety, and mood disorders. The relative effectiveness of varenicline, bupropion, and NRT versus placebo did not vary across psychiatric diagnoses.

Patient-Informed Treatment Development of Behavioral Smoking Cessation for People With Schizophrenia

The objective of this study was to use qualitative methodology to tailor and refine an existing smoking cessation intervention for the population of people who use cigarettes and are diagnosed with schizophrenia, schizoaffective, or psychotic disorder. Successive cohort design methodology was used to iteratively modify the treatment in response to qualitative participant, therapist, and consultant feedback on the intervention. Qualitative methodology for participant feedback included analysis of semistructured interviews with participants, visualization of app utilization data, and stakeholder feedback from study therapists and consultants. Using the successive cohort design, a tailored multicomponent mobile health smoking cessation intervention was developed. The intervention included mobile contingency management (i.e., financial compensation for confirmed abstinence from smoking), pharmacotherapy for smoking cessation, cognitive-behavioral counseling sessions, and the Stay Quit app for relapse prevention. Two cohorts (N = 13) were completed in the study; after each cohort, the treatment protocol was revised. The intervention is described, as well as the qualitative findings from each cohort and subsequent changes made to the intervention based upon patient and provider feedback. Metrics of patient engagement included treatment adherence (40% in Cohort 1 and 63% in Cohort 2). Both participants and therapists reported that the intervention was helpful. Over one third of participants self-reported abstinence at posttreatment. Since qualitative methodology is often underutilized in mental health treatment development, this study demonstrates the utility of the successive cohort design for treatment development of behavior change interventions for at-risk, vulnerable populations.

Patterns of tobacco use, quit attempts, readiness to quit and self-efficacy among smokers with anxiety or depression: Findings among six countries of the EUREST-PLUS ITC Europe Surveys

INTRODUCTION

We compared smoking behaviors, past quit attempts, readiness to quit and beliefs about quitting among current cigarette smokers with probable anxiety or depression (PAD) to those without PAD, from six European Union (EU) Member States (MS).

METHODS

A nationally representative cross-sectional sample of 6011 adult cigarette smokers from six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain) was randomly selected through a multistage cluster sampling design in 2016. Respondents were classified as having PAD based on self-reported current diagnosis or treatment for anxiety or depression, or a positive screen for major depression, according to a validated two-item instrument. Sociodemographic characteristics, patterns of tobacco use, past quitting, readiness to quit, self-efficacy and beliefs about quitting were assessed for patients with and without PAD. Logistic regression was used to examine predictors of PAD. All analyses were conducted using the complex samples package of SPSS.

RESULTS

Among smokers sampled, 21.0% (95% CI: 19.3-22.9) were identified as having PAD. Logistic regression analyses controlling for socioeconomic variables and cigarettes smoked per day found smokers with PAD were more likely to have made an attempt to quit smoking in the past (AOR=1.48; 95% CI: 1.25-1.74), made a quit attempt in the last 12 months (AOR=1.75; 95% CI: 1.45-2.11), and report lower self-efficacy with quitting (AOR=1.83; 95% CI: 1.44-2.32) compared to smokers without PAD. Additionally, it was found that individuals with PAD were more likely to report having received advice to quit from a doctor or health professional and having used quitline support as part of their last quit attempt.

CONCLUSIONS

Smokers with PAD report a greater interest in quitting in the future and more frequent failed quit attempts than smokers without PAD; however, the high rates of untreated anxiety or depression, nicotine dependence, low confidence in the ability to quit, infrequent use of cessation methods, as well as socioeconomic factors may make quitting difficult.

A tele-mentoring tobacco cessation case consultation and education model for healthcare providers in community mental health centers

Smoking prevalence among individuals with mental and behavioral health needs is considerably higher compared to the general population, but evidence-based smoking cessation therapies are underutilized in mental and behavioral healthcare settings, despite the fact that these treatments are both safe and effective. The goal of this paper is to present the background, design and pilot of Project TEACH (Tobacco Education and Cessation in the Health System) developed to improve clinical practice by offering specialized training in the provision of smoking cessation interventions to care providers in community mental health centers in Texas. This is achieved through engaging the expertise of clinicians at the MD Anderson Cancer Center’s Tobacco Treatment Program and disseminating this expertise to care providers by means of a novel tele-mentoring approach called Project ECHO (Extension for Community Healthcare Outcomes). Evaluation of our pilot ECHO training project demonstrated that the training was very well received and resulted in self-reported enhancement of the providers’ professional practice. This is the first project to extend the collaborative ECHO model to train healthcare providers in smoking cessation. This approach has potential to reduce smoking rates among smokers with mental and behavioral health needs, and consequently contribute to the prevention of cancer and other chronic diseases in this vulnerable population.

[Somatic risks in elderly people with severe psychiatric illnesses]

BACKGROUND

Aged patients with severe mental illness (SMI) suffer from a high risk for functional impairment and a high load of somatic comorbidities. Until now, there has been a lack of systematic studies on this patient population in later life. This review summarizes the most significant somatic comorbidities and discusses the consequences for the medical care of this elderly group of patients.

METHODS

A selective narrative review based on PubMed research and observations in clinical practice.

RESULTS

Life expectancy is shortened by approximately 10 years in patients with SMI. The main reasons are somatic comorbidities, particularly lung and respiratory tract disorders, metabolic syndrome with its subsequent cardiovascular complications, in addition to osteoporosis and fractures with a complicated clinical course. Although life expectancy is shortened, the number of geriatric patients with SMI is increasing and requires special attention to be given to out-patient psychosocial care, self-management of somatic diseases, and to age-appropriate continuation of psychiatric treatment.

CONCLUSION

The life expectancy of patients with SMI is reduced because of their typically somatic comorbidity, but they are reaching increasingly advanced ages as a consequence of improved treatment possibilities. They often require special attention in their diagnostic work-up and support in the management of their treatment. Collaborative care linking medical geriatric and geronto-psychiatric treatment facilities is helpful in the the interdisciplinary therapy required.