Combination Extended Smoking Cessation Treatment Plus Home Visits for Smokers With Schizophrenia: A Randomized Controlled Trial

Abstract

Introduction: The majority of people with schizophrenia have a diagnosis of tobacco dependence during their lifetime. A major obstacle to reducing the burden of cigarette smoking in this population is that these smokers have lower quit rates when undergoing standard treatment compared to smokers with no mental illness. We sought to determine if combination extended treatment (COMB-EXT) and home visits (HV) would lead to improved outcomes in smokers with schizophrenia. Methods: Thirty-four cigarette smokers with schizophrenia completed either COMB-EXT with HV, COMB-EXT without HV, or treatment as usual (TAU) (random assignment). COMB-EXT consisted of group cognitive-behavioral therapy (CBT), bupropion, nicotine patch, and nicotine lozenge, which were initiated within 2 weeks and continued for 26 weekly visits. HV consisted of biweekly visits to the home with assessment of secondhand smoke (SHS) exposure and brief behavioral therapy with participants and others in the home environment. TAU consisted of group CBT plus serial single or combination medication trials as per standard care. Results: Smokers with schizophrenia who received COMB-EXT (with or without HV) had greater reductions in cigarettes per day than those treated with TAU (both ps < .01). In addition, 7-day point prevalence abstinence rates for the three groups were 45%, 20%, and 8%, respectively, which was significantly higher for COMB-EXT plus HV than TAU (χ 2 (1) = 4.8, p = .03). Groups did not differ significantly in the number of adverse events, and HV were easily scheduled. Conclusion: COMB-EXT improves outcomes for smokers with schizophrenia. HV appeared to provide additional benefit for smoking cessation in this treatment-resistant population. Implications: The clear benefit found here of rapidly initiated, combination, extended treatment over TAU suggests that aggressive and extended treatment should be considered in clinical practice for smokers with schizophrenia. Furthermore, HV to address SHS exposure showed initial promise for assisting smokers with schizophrenia in maintaining abstinence, indicating that this intervention may be worthy of future research.

Achieving Smoking Cessation in Individuals with Schizophrenia: Special Considerations

“…These studies support the use of bupropion with or without NRT in smokers with schizophrenia, with active treatment increasing abstinence rates 2–5 fold over placebo or treatment as usual [36, 37, 40, 43, 49, 52, 53]. Importantly, there is no evidence for worsening of positive, negative, or depressive symptoms in those assigned to receive bupropion with or without NRT as compared to placebo in any of these trials individually or in aggregate [36, 37, 39–41, 43].…”

“…There is consistent clinical trial evidence for efficacy and tolerability of bupropion, either alone or in combination with NRT, for smoking cessation specifically for those with schizophrenia [36, 39–41, 43]. This has been confirmed in independent, systematic reviews and meta-analyses [37, 49–51] and incorporated into clinical practice guidelines.…”

“…Although smokers with schizophrenia have been excluded from most major clinical trials of nicotine dependence treatments [34, 35], a growing body of evidence supports the safety and efficacy of first-line smoking cessation pharmacotherapies for smokers with schizophrenia, including varenicline, bupropion with and without nicotine replacement therapy (NRT), and nicotine patch monotherapy [36–46]. We summarize the evidence from randomized, placebo-controlled trials published from 2000 through 2016 of pharmacotherapies added to behavioral treatment, with biochemically-validated abstinence outcomes in adult outpatient smokers with schizophrenia spectrum disorders.…”

Tobacco retail environment near housing programmes for patients with mental health conditions in New York City

“…Existing tobacco programmes and policies for smokers with MH conditions commonly focus on MH symptom management,10–12 assisting with heavy nicotine dependence or cravings,13 banning smoking in psychiatric hospitals,14 assessing social influences or smoking in the home,15 and increasing patient access to evidence-based tobacco treatments 16…”

Views and Preferences for Nicotine Products as an Alternative to Smoking: A Focus Group Study of People Living with Mental Disorders

“…There is some evidence that the long-term use of nicotine products in conjunction with psychological therapies or education may be effective in maintaining smoking cessation for people with schizophrenia [20,21,22]. …”