October 24, 2023
• Research Highlight

People with serious mental illness (SMI), such as schizophrenia, bipolar disorder, and major depression, often face significant physical health challenges. For example, people with SMI die from cardiovascular disease at twice the rate of those without SMI, and levels of tobacco smoking in this population are high.

Although smoking is the greatest contributor to preventable death in people with SMI, they are less likely than people without SMI to receive treatment to quit smoking. When treatment to quit smoking is provided, it seldom addresses the potential for weight gain. People often gain weight when they quit smoking, and people with SMI already face an increased risk of obesity.

The negative impact of tobacco use, cardiovascular disease, and obesity on people with SMI highlights the critical need for scalable interventions that address these multiple health concerns.

What did the researchers do?

In a study funded by the National Institute of Mental Health and published in JAMA Psychiatry, Gail Daumit, M.D., of Johns Hopkins University, A. Eden Evins, M.D., of Massachusetts General Hospital and Harvard Medical School, and colleagues developed an 18-month community-based tobacco smoking cessation intervention. The intervention, which consisted of pharmacologic and behavioral components (including weight management), was tested at four community mental health programs in Maryland.

People were eligible to participate in the study if they had a diagnosed SMI, smoked tobacco daily, and were willing to attempt smoking cessation within six months. At the beginning of the study, all participants reported their readiness to quit smoking within six months but not within one month versus within one month. The researchers then randomly assigned participants to either an intervention group or a control group that did not receive the intervention.

Control group

Participants assigned to the control group were given:

• The number to a telephone-based smoking quit line that offered free nicotine replacement therapy
• A list of exercise resources and the “Aim for a Healthy Weight ” booklet from the National Heart, Lung, and Blood Institute
• Quarterly health information newsletters

Intervention group

Participants assigned to the intervention group who reported not being ready to quit smoking within 1 month took part in a 4-week motivational enhancement group designed to increase their motivation to quit smoking. Those who reported being ready to quit smoking within 1 month took part in a 7-week behavioral smoking cessation group. Participants could repeat groups as often as necessary or move between the groups if their readiness to quit smoking changed. Participants were offered smoking cessation medication regardless of their initial interest in quitting. Participants who successfully quit smoking and maintained smoking abstinence for at least 1 week attended ongoing relapse prevention groups and were encouraged to continue using smoking cessation medication.

During the behavioral intervention, participants were offered:

• One 1-hour group smoking cessation/weight management session per week
• One 20-minute individual smoking cessation/weight management session per week
• Support for physical activity
• Text messages that supported health behavior change

During the group and individual smoking cessation/weight management sessions, researchers provided participants with content such as information about the benefits and methods of quitting smoking, help to identify smoking triggers, and more. Participants in the intervention group were also given access to group exercise classes and incentives for participating in the intervention, including small monetary compensation for group attendance and medallions linked to the achievement of health milestones.

Measured outcomes

Participants in both the intervention and control groups had their weight and smoking abstinence (i.e., 7 straight days of not smoking tobacco) measured at 6, 12, 15, and 18 months after the start of the intervention. In addition to these measures, at 18 months, the researchers measured participants’ cardiovascular health, including their 10-year risk of having a cardiovascular event and their cardiovascular risk factors such as systolic blood pressure, total cholesterol, diabetes status, triglyceride levels, and fasting glucose.

What were the results of the intervention?

The researchers found that at 18 months, 26.4% of people in the intervention group achieved smoking abstinence compared with 5.7% of people in the control group. Participants in the intervention group were also more likely to achieve smoking abstinence at 6, 12, and 15 months compared with the control group. The ability to achieve abstinence from smoking at 18 months was not significantly impacted by participants’ readiness to quit nor by psychiatric diagnosis, sex, or race.

Participants in the interventions group also had a 12.7% drop in their 10-year risk for experiencing a cardiovascular event, while this risk increased by 3.6% in the control group. No significant difference in weight change was seen between the control (-1.4 kg) and intervention (+0.2 kg) groups.

Why does the study matter?

The results of the study suggest that providing extended smoking cessation support to people with SMI can be effective at reducing smoking and improving cardiovascular health—even if people report they are not ready to quit smoking right away. The researchers suggest that making evidence-based smoking cessation programs with medication and counseling more available to people with SMI could help reduce disparities in tobacco-related mortality seen between people with SMI and the general population.

Reference

Daumit, G. L., Evins, A. E., Cather, C., Dalcin, A. T., Dickerson, F. B., Miller, E. R., III, Appel, L. J., Jerome, G. J., McCann, U., Ford, D. E., Charleston, J. B., Young, D. R., Gennusa, J. V., III, Goldsholl, S., Cook, C., Fink, T., & Wang, N.-Y. (2023). Effect of a tobacco cessation intervention incorporating weight management for adults with serious mental illness: A randomized clinical trial. JAMA Psychiatry, 80(9), 895−904. https://doi.org/10.1001/jamapsychiatry.2023.1691 

Grant

MH104553 

Clinical Trial

NCT02424188