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Peckham E, Arundel C, Bailey D, Crosland S, Fairhurst C, Heron P, Hewitt C, Li J, Parrott S, Bradshaw T, Horspool M, Hughes E, Hughes T, Ker S, Leahy M, McCloud T, Osborn D, Reilly J, Steare T, Ballantyne E, Bidwell P, Bonner S, Brennan D, Callen T, Carey A, Colbeck C, Coton D, Donaldson E, Evans K, Herlihy H, Khan W, Nyathi L, Nyamadzawo E, Oldknow H, Phiri P, Rathod S, Rea J, Romain-Hooper CB, Smith K, Stribling A, Vickers C, Gilbody S. A bespoke smoking cessation service compared with treatment as usual for people with severe mental ill health: the SCIMITAR+ RCT. Health Technol Assess 2020; 23:1-116. [PMID: 31549622 DOI: 10.3310/hta23500] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND There is a high prevalence of smoking among people with severe mental ill health (SMI). Helping people with SMI to quit smoking could improve their health and longevity, and reduce health inequalities. However, those with SMI are less likely to access and engage with routine smoking cessation services than the general population. OBJECTIVES To compare the clinical effectiveness and cost-effectiveness of a bespoke smoking cessation (BSC) intervention with usual stop smoking services for people with SMI. DESIGN A pragmatic, two-arm, individually randomised controlled trial. SETTING Primary care and secondary care mental health services in England. PARTICIPANTS Smokers aged ≥ 18 years with SMI who would like to cut down on or quit smoking. INTERVENTIONS A BSC intervention delivered by mental health specialists trained to deliver evidence-supported smoking cessation interventions compared with usual care. MAIN OUTCOME MEASURES The primary outcome was self-reported, CO-verified smoking cessation at 12 months. Smoking-related secondary outcomes were self-reported smoking cessation, the number of cigarettes smoked per day, the Fagerström Test for Nicotine Dependence and the Motivation to Quit questionnaire. Other secondary outcomes were Patient Health Questionnaire-9 items, Generalised Anxiety Disorder Assessment-7 items and 12-Item Short-Form Health Survey, to assess mental health and body mass index measured at 6 and 12 months post randomisation. RESULTS The trial randomised 526 people (265 to the intervention group, 261 to the usual-care group) aged 19 to 72 years (mean 46 years). About 60% of participants were male. Participants smoked between 3 and 100 cigarettes per day (mean 25 cigarettes per day) at baseline. The intervention group had a higher rate of exhaled CO-verified smoking cessation at 6 and 12 months than the usual-care group [adjusted odds ratio (OR) 12 months: 1.6, 95% confidence interval (CI) 0.9 to 2.8; adjusted OR 6 months: 2.4, 95% CI 1.2 to 4.7]. This was not statistically significant at 12 months (p = 0.12) but was statistically significant at 6 months (p = 0.01). In total, 111 serious adverse events were reported (69 in the BSC group and 42 in the usual-care group); the majority were unplanned hospitalisations due to a deterioration in mental health (n = 98). The intervention is likely (57%) to be less costly but more effective than usual care; however, this result was not necessarily associated with participants' smoking status. LIMITATIONS Follow-up was not blind to treatment allocation. However, the primary outcome included a biochemically verified end point, less susceptible to observer biases. Some participants experienced difficulties in accessing nicotine replacement therapy because of changes in service provision. Efforts were made to help participants access nicotine replacement therapy, but this may have affected participants' quit attempt. CONCLUSIONS People with SMI who received the intervention were more likely to have stopped smoking at 6 months. Although more people who received the intervention had stopped smoking at 12 months, this was not statistically significant. FUTURE WORK Further research is needed to establish how quitting can be sustained among people with SMI. TRIAL REGISTRATION Current Controlled Trials ISRCTN72955454. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 50. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Emily Peckham
- Department of Health Sciences, University of York, York, UK
| | | | - Della Bailey
- Department of Health Sciences, University of York, York, UK
| | | | | | - Paul Heron
- Department of Health Sciences, University of York, York, UK
| | | | - Jinshuo Li
- Department of Health Sciences, University of York, York, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, York, UK
| | - Tim Bradshaw
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Michelle Horspool
- Research and Development, Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
| | | | - Tom Hughes
- Research and Development, Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - Suzy Ker
- North East York Community Mental Health Team, Tees, Esk and Wear Valleys NHS Foundation Trust, York, UK
| | - Moira Leahy
- Research and Development, Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
| | - Tayla McCloud
- Division of Psychiatry, University College London, London, UK
| | - David Osborn
- Division of Psychiatry, University College London, London, UK
| | - Joseph Reilly
- North East York Community Mental Health Team, Tees, Esk and Wear Valleys NHS Foundation Trust, York, UK
| | - Thomas Steare
- Division of Psychiatry, University College London, London, UK
| | - Emma Ballantyne
- Research and Development, Rotherham Doncaster and South Humber NHS Foundation Trust, Doncaster, UK
| | - Polly Bidwell
- Research and Development, Lancashire Care NHS Foundation Trust, Preston, UK
| | - Susan Bonner
- Research and Development, Tees, Esk and Wear Valleys NHS Foundation Trust, Stockton on Tees, UK
| | - Diane Brennan
- Research and Development, Lincolnshire Partnership NHS Foundation Trust, Sleaford, UK
| | - Tracy Callen
- Research and Development, Solent NHS Trust, Portsmouth, UK
| | - Alex Carey
- Research and Development, Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
| | - Charlotte Colbeck
- Research and Development, Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
| | - Debbie Coton
- Research and Development, Sussex Partnership NHS Foundation Trust, Hove, UK
| | - Emma Donaldson
- Research and Development, Berkshire Healthcare NHS Foundation Trust, Reading, UK
| | - Kimberley Evans
- Research and Development, Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Hannah Herlihy
- Research and Development, Kent and Medway NHS and Social Care Partnership Trust, Maidstone, UK
| | - Wajid Khan
- Research and Development, South West Yorkshire Partnership NHS Foundation Trust, Wakefield, UK
| | - Lizwi Nyathi
- Research and Development, Lincolnshire Partnership NHS Foundation Trust, Sleaford, UK
| | - Elizabeth Nyamadzawo
- Research and Development, Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Helen Oldknow
- Research and Development, Rotherham Doncaster and South Humber NHS Foundation Trust, Doncaster, UK
| | - Peter Phiri
- Research and Development, Southern Health NHS Foundation Trust, Southampton, UK
| | - Shanaya Rathod
- Research and Development, Southern Health NHS Foundation Trust, Southampton, UK
| | - Jamie Rea
- Research and Development, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Kaye Smith
- Research and Development, Solent NHS Trust, Portsmouth, UK
| | - Alison Stribling
- Research and Development, Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Carinna Vickers
- Research and Development, Somerset Partnership NHS Foundation Trust, South Petherton, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
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Gilbody S, Peckham E, Bailey D, Arundel C, Heron P, Crosland S, Fairhurst C, Hewitt C, Li J, Parrott S, Bradshaw T, Horspool M, Hughes E, Hughes T, Ker S, Leahy M, McCloud T, Osborn D, Reilly J, Steare T, Ballantyne E, Bidwell P, Bonner S, Brennan D, Callen T, Carey A, Colbeck C, Coton D, Donaldson E, Evans K, Herlihy H, Khan W, Nyathi L, Nyamadzawo E, Oldknow H, Phiri P, Rathod S, Rea J, Romain-Hooper CB, Smith K, Stribling A, Vickers C. Smoking cessation for people with severe mental illness (SCIMITAR+): a pragmatic randomised controlled trial. Lancet Psychiatry 2019; 6:379-390. [PMID: 30975539 PMCID: PMC6546931 DOI: 10.1016/s2215-0366(19)30047-1] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/19/2019] [Accepted: 01/20/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND People with severe mental illnesses such as schizophrenia are three times more likely to smoke than the wider population, contributing to widening health inequalities. Smoking remains the largest modifiable risk factor for this health inequality, but people with severe mental illness have not historically engaged with smoking cessation services. We aimed to test the effectiveness of a combined behavioural and pharmacological smoking cessation intervention targeted specifically at people with severe mental illness. METHODS In the smoking cessation intervention for severe mental illness (SCIMITAR+) trial, a pragmatic, randomised controlled study, we recruited heavy smokers with bipolar disorder or schizophrenia from 16 primary care and 21 community-based mental health sites in the UK. Participants were eligible if they were aged 18 years or older, and smoked at least five cigarettes per day. Exclusion criteria included substantial comorbid drug or alcohol problems and people who lacked capacity to consent at the time of recruitment. Using computer-generated random numbers, participants were randomly assigned (1:1) to a bespoke smoking cessation intervention or to usual care. Participants, mental health specialists, and primary care physicians were unmasked to assignment. The bespoke smoking cessation intervention consisted of behavioural support from a mental health smoking cessation practitioner and pharmacological aids for smoking cessation, with adaptations for people with severe mental illness-such as, extended pre-quit sessions, cut down to quit, and home visits. Access to pharmacotherapy was via primary care after discussion with the smoking cessation specialist. Under usual care participants were offered access to local smoking cessation services not specifically designed for people with severe mental illnesses. The primary endpoint was smoking cessation at 12 months ascertained via carbon monoxide measurements below 10 parts per million and self-reported cessation for the past 7 days. Secondary endpoints were biologically verified smoking cessation at 6 months; number of cigarettes smoked per day, Fagerström Test for Nicotine Dependence (FTND) and Motivation to Quit (MTQ) questionnaire; general and mental health functioning determined via the Patient Health Questionnaire-9 (PHQ-9), the Generalised Anxiety Disorder-7 (GAD-7) questionnaire, and 12-Item Short Form Health Survey (SF-12); and body-mass index (BMI). This trial was registerd with the ISRCTN registry, number ISRCTN72955454, and is complete. FINDINGS Between Oct 7, 2015, and Dec 16, 2016, 526 eligible patients were randomly assigned to the bespoke smoking cessation intervention (n=265) or usual care (n=261). 309 (59%) participants were male, median age was 47·2 years (IQR 36·3-54·5), with high nicotine dependence (mean 24 cigarettes per day [SD 13·2]), and the most common severe mental disorders were schizophrenia or other psychotic illness (n=343 [65%]), bipolar disorder (n=115 [22%]), and schizoaffective disorder (n=66 [13%]). 234 (88%) of intervention participants engaged with the treatment programme and attended 6·4 (SD 3·5) quit smoking sessions, with an average duration of 39 min (SD 17; median 35 min, range 5-120). Verified quit data at 12 months were available for 219 (84%) of 261 usual care and 223 (84%) of 265 intervention participants. The proportion of participants who had quit at 12 months was higher in the intervention group than in the usual care group, but non-significantly (34 [15%] of 223 [13% of those assigned to group] vs 22 [10%] of 219 [8% of those assigned to group], risk difference 5·2%, 95% CI -1·0 to 11·4; odds ratio [OR] 1·6, 95% CI 0·9 to 2·9; p=0·10). The proportion of participants who quit at 6 months was significantly higher in the intervention group than in the usual care group (32 [14%] of 226 vs 14 [6%] of 217; risk difference 7·7%, 95% CI 2·1 to 13·3; OR 2·4, 95% CI 1·2 to 4·6; p=0·010). The incidence rate ratio for number of cigarettes smoked per day at 6 months was 0·90 (95% CI 0·80 to 1·01; p=0·079), and at 12 months was 1·00 (0·89 to 1·13; p=0·95). At both 6 months and 12 months, the intervention group was non-significantly favoured in the FTND (adjusted mean difference 6 months -0·18, 95% CI -0·53 to 0·17, p=0·32; and 12 months -0·01, -0·39 to 0·38, p=0·97) and MTQ questionnaire (adjusted mean difference 0·58, -0·01 to 1·17, p=0·056; and 12 months 0·64, 0·04 to 1·24, p=0·038). The PHQ-9 showed no difference between the groups (adjusted mean difference at 6 months 0·20, 95% CI -0·85 to 1·24 vs 12 months -0·12, -1·18 to 0·94). For the SF-12 survey, we saw evidence of improvement in physical health in the intervention group at 6 months (adjusted mean difference 1·75, 95% CI 0·21 to 3·28), but this difference was not evident at 12 months (0·59, -1·07 to 2·26); and we saw no difference in mental health between the groups at 6 or 12 months (adjusted mean difference at 6 months -0·73, 95% CI -2·82 to 1·36, and 12 months -0·41, -2·35 to 1·53). The GAD-7 questionnaire showed no difference between the groups (adjusted mean difference at 6 months -0·32 95% CI -1·26 to 0·62 vs 12 months -0·10, -1·05 to 0·86). No difference in BMI was seen between the groups (adjusted mean difference 6 months 0·16, 95% CI -0·54 to 0·85; 12 months 0·25, -0·62 to 1·13). INTERPRETATION This bespoke intervention is a candidate model of smoking cessation for clinicians and policy makers to address high prevalence of smoking. The incidence of quitting at 6 months shows that smoking cessation can be achieved, but the waning of this effect by 12 months means more effort is needed for sustained quitting. FUNDING National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Simon Gilbody
- Department of Health Sciences, University of York, York, UK.
| | - Emily Peckham
- Department of Health Sciences, University of York, York, UK
| | - Della Bailey
- Department of Health Sciences, University of York, York, UK
| | | | - Paul Heron
- Department of Health Sciences, University of York, York, UK
| | | | | | | | - Jinshuo Li
- Department of Health Sciences, University of York, York, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, York, UK
| | - Tim Bradshaw
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Michelle Horspool
- Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
| | | | - Tom Hughes
- Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - Suzy Ker
- Tees, Esk and Wear Valleys NHS Foundation Trust, Stockton-on-Tees, UK
| | - Moira Leahy
- Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
| | - Tayla McCloud
- Division of Psychiatry, University College London, London, UK
| | - David Osborn
- Division of Psychiatry, University College London, London, UK
| | - Joe Reilly
- Tees, Esk and Wear Valleys NHS Foundation Trust, Stockton-on-Tees, UK
| | - Thomas Steare
- Division of Psychiatry, University College London, London, UK
| | - Emma Ballantyne
- Rotherham Doncaster and South Humber NHS Foundation Trust, Doncaster, UK
| | | | - Sue Bonner
- Tees, Esk and Wear Valleys NHS Foundation Trust, Stockton-on-Tees, UK
| | - Diane Brennan
- Lincolnshire Partnership NHS Foundation Trust, Lincoln, UK
| | | | - Alex Carey
- Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
| | - Charlotte Colbeck
- Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK
| | - Debbie Coton
- Sussex Partnership NHS Foundation Trust, Hove, UK
| | | | | | - Hannah Herlihy
- Kent and Medway NHS and Social Care Partnership Trust, Maidstone, UK
| | - Wajid Khan
- South West Yorkshire NHS Foundation Trust, Wakefield, UK
| | - Lizwi Nyathi
- Lincolnshire Partnership NHS Foundation Trust, Lincoln, UK
| | | | - Helen Oldknow
- Rotherham Doncaster and South Humber NHS Foundation Trust, Doncaster, UK
| | - Peter Phiri
- Southern Health NHS Foundation Trust, Southampton, UK
| | | | - Jamie Rea
- Northumberland Tyne and Wear NHS Foundation Trust, Newcastle, UK
| | | | - Kaye Smith
- Solent NHS Foundation Trust, Southampton, UK
| | | | - Carinna Vickers
- Somerset Partnership NHS Foundation Trust, South Petherton, UK
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