Treating Tobacco Dependence at the Intersection of Diversity, Poverty, and Mental Illness: A Randomized Feasibility and Replication Trial

Abstract

Introduction: In an ethnically-diverse, uninsured psychiatric sample with co-occurring drug/alcohol addiction, we evaluated the feasibility and reproducibility of a tobacco treatment intervention. The intervention previously demonstrated efficacy in insured psychiatric and nonpsychiatric samples with 20.0%-25.0% abstinence at 18 months. Methods: Daily smokers, recruited in 2009-2010 from psychiatric units at an urban public hospital, were randomized to usual care (on-unit nicotine replacement plus quit advice) or intervention, which added a Transtheoretical-model tailored, computer-assisted intervention, stage-matched manual, brief counseling, and 10-week post-hospitalization nicotine replacement. Results: The sample (N = 100, 69% recruitment rate, age M = 40) was 56% racial/ethnic minority, 65% male, 79% unemployed, and 48% unstably housed, diagnosed with unipolar (54%) and bipolar (14%) depression and psychotic disorders (46%); 77% reported past-month illicit drug use. Prior to hospitalization, participants averaged 19 (SD = 11) cigarettes/day for 23 (SD = 13) years; 80% smoked within 30 minutes of awakening; 25% were preparing to quit. Encouraging and comparable to effects in the general population, 7-day point prevalence abstinence for intervention versus control was 12.5% versus 7.3% at 3 months, 17.5% versus 8.5% at 6 months, and 26.2% versus 16.7% at 12 months. Retention exceeded 80% over 12 months. The odds of abstinence increased over time, predicted by higher self-efficacy, greater perceived social status, and diagnosis of psychotic disorder compared to unipolar depression. Conclusions: Findings indicate uninsured smokers with serious mental illness can engage in tobacco treatment research with quit rates comparable to the general population. A larger investigation is warranted. Inclusion of diverse smokers with mental illness in clinical trials is supported and encouraged.

Treating Smoking in Adults With Co-occurring Acute Psychiatric and Addictive Disorders

“…The studies (n=224 recruited 2006–2008 and n=100 recruited 2009–2010) had common inclusion/exclusion criteria measures and procedures (Hickman, et al, 2015; J. J. Prochaska, et al, 2014).…”

“…The intervention group at 3 and 6 months post-hospitalization repeated the computer intervention, which stored their previous entries providing ipsative feedback on how they changed over time, recommending next steps toward quitting smoking and maintaining abstinence. The intervention has been reported on previously (Hickman, et al, 2015; J. J. Prochaska, et al, 2014).…”

“…Herein, we report on smoking cessation and recovery outcomes analyzing data on smokers with mental illness and SUD treated for tobacco use in two randomized controlled trials (Hickman, Delucchi and Prochaska, 2015; J. J. Prochaska, Hall, Delucchi, et al, 2014).…”

Smoking Cessation and Electronic Cigarettes in Community Mental Health Centers: Patient and Provider Perspectives

“…The 2008 US Public Health Service (PHS) Clinical Practice Guideline Panel recommends the 5A's (Ask, Advise, Assess, Assist, Arrange) to increase patients' engagement in smoking cessation treatments (Fiore and Baker 2011; Fiore et al 2008). In general, patients with SMI benefit from evidence-based treatment such as pharmacotherapy (bupropion, varenicline) and counseling; although, less data is available in this population (Evins et al 2007, 2005, 2014; Hickman et al 2015; Kishi and Iwata 2015; Roberts et al 2016; Tsoi et al 2013; Ziedonis and George 1997). Community Mental Health Centers (CMHCs) appear to be ideal venues for the delivery of smoking cessation treatment to the SMI population.…”

Commentary on Roberts et al. (2016): Bupropion and varenicline are efficacious and well‐tolerated cessation medications for smokers with serious mental illness

“…Two recent trials on acute in-patient psychiatry units recruited smokers with varied diagnoses, varying in readiness to quit [8,9]. Relative to placebo, the stage-tailored cessation intervention combined with NRT resulted in a twofold greater abstinence and without adverse effects on mental health recovery.…”