In individuals with serious mental illness, tobacco smoking is common. While estimates vary, it has been reported that as many as 70-85% of individuals with schizophrenia and 50-70% of those with bipolar disorder smoke. Smoking significantly increases risk of cardiovascular disease; additionally, in persons with serious mental illness, the effects of smoking are often compounded by other cardiovascular disease risk factors common in this population, including obesity, hypertension, dyslipidemia, diabetes mellitus and risk behaviors such as physical inactivity and unhealthy diet.
Although smoking cessation interventions combining pharmacotherapy and behavioral treatment have been shown to be effective in achieving abstinence, smoking cessation interventions are not routinely offered to individuals with serious mental illness in community settings, especially to those not seeking to quit smoking immediately.
A recent study including Mass General researchers Eden Evins, MD, MPH and Corinne Cather, PhD examines the effectiveness of an 18-month pharmacotherapy and behavioral smoking cessation intervention incorporating weight management and support for physical activity in adults with serious mental illness who were daily smokers interested in quitting smoking within 1 or 6 months.
This randomized clinical trial was conducted between 2016 and 2020 at four community health programs. Of the 192 persons enrolled in the study, the mean [SD] age was 49.6 [11.7] years and 97 were women (50.5%). A total of 82 participants (42.7%) carried a diagnosis of a schizophrenia spectrum disorder, 62 (32.3%) had bipolar disorder, and 48 (25.0%) had major depressive disorder. Participants self-identified with the following race and ethnicity categories: Black or African American (48.4%), Hispanic or Latino (3.1%), White (46.9%), and other (4.7%).
Participants were randomly assigned to intervention or control groups. The intervention consisted of a comprehensive approach combining pharmacotherapy and behavioral treatment. Pharmacotherapy consisted primarily of varenicline, dual-form nicotine replacement, or a combination of the two. Participants also received tailored individual and group counseling for motivational enhancement, smoking cessation and relapse prevention, weight management counseling, and support for physical activity. Individuals in the control group received quitline referrals but did not receive additional support.
At 18 months, 27.8% of the participants in the intervention group, compared to 5.7% of the control group, achieved abstinence. This represents a nearly sixfold increase in the odds of achieving abstinence for individuals who received the intervention (adjusted odds ratio [OR], 5.9; 95% CI, 2.3-15.4). Participants’ readiness to quit in 1month (versus 6 months) did not affect the likelihood of achieving abstinence.
In addition, the intervention group did not have significantly greater weight gain than the control group. This outcome is particularly important, as weight gain often poses a barrier to smoking cessation for many individuals.
Next Steps
In individuals with serious mental illness, smoking cessation represents a clinical challenge. Although rates of smoking in the general population have been falling, the prevalence of tobacco use in this population remains alarmingly high. Smoking cessation, while undeniably beneficial, is complicated by a number of unique factors in this population. Individuals with serious mental illness often encounter barriers in accessing comprehensive cessation programs, and chronic symptoms may interfere with their ability to adhere to cessation programs. Additionally, it is believed that nicotine may ameliorate the cognitive deficits associated with severe psychiatric illness and may also help to alleviate medication side effects.
The findings of this randomized clinical trial showed that in individuals with serious mental illness who are interested in quitting smoking within 6 months, an 18-month intervention with first-line pharmacotherapy and tailored behavioral support for smoking cessation and weight management increased tobacco abstinence without significant weight gain. Future research is needed to assess long-term relapse rates, but more importantly, future endeavors must focus on how to better encourage smoking cessation in individuals with serious mental illness and how to incorporate effective smoking cessation interventions into community healthcare settings.
Read More
Daumit GL, Evins AE, Cather C, Dalcin AT, Dickerson FB, Miller ER 3rd, Appel LJ, Jerome GJ, McCann U, Ford DE, Charleston JB, Young DR, Gennusa JV 3rd, Goldsholl S, Cook C, Fink T, Wang NY. Effect of a Tobacco Cessation Intervention Incorporating Weight Management for Adults With Serious Mental Illness: A Randomized Clinical Trial. JAMA Psychiatry. 2023 Jun 28: e231691.
In the News
Eden Evins, MD, MPH, is the Founding Director and Principal Investigator in the Center for Addiction Medicine and the Cox Family Professor of Psychiatry in the Field of Addiction Medicine at Harvard Medical School. Her research has focused on of the efficacy of pharmacotherapeutic cessation aids in smokers with and without serious mental illness, and on the effect of nicotine on cognitive performance in those with and without schizophrenia. A newer line of investigation explores the effect of cannabis on psychiatric symptoms, cognitive function, and addictive behaviors.
Corinne Cather, PhD is the Director of the MGH Center of Excellence for Psychosocial and Systemic Research and and an Associate Professor of Psychology at Harvard Medical School. Her research has focused on psychosocial interventions to promote physical health, improve functioning, and decrease distress in individuals with first episode and early psychosis as well as in those with longer histories of mental health challenges.
