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People with serious mental illness (SMI), such as schizophrenia, bipolar disorderand great 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 tobacco smoking levels in this population are high.
Although smoking is the largest contributor to preventable death in people with SMI, they are less likely to receive smoking cessation treatment than people without SMI. When smoking cessation treatment is provided, it rarely addresses potential weight gain. People often gain weight when they stop smoking, and people with SMI already face an increased risk of obesity.
The negative impact of smoking, cardiovascular disease and obesity on people with SMI highlights the critical need for scalable interventions that address these multiple health problems.
What did the researchers do?
In a study funded by the National Institute of Mental Health, published in JAMA Psychiatry, Gail Daumit, MD, of Johns Hopkins University, A. Eden Evins, MD, of Massachusetts General Hospital and Harvard Medical School, and colleagues developed an 18-month community-based tobacco cessation intervention. The intervention, which consisted of pharmacological and behavioral components (including weight management), was tested in four community mental health programs in Maryland.
Individuals were eligible to participate in the study if they had been diagnosed with SMI, smoked tobacco daily, and were willing to try to quit smoking within six months. At the start of the study, all participants reported that they were ready to quit smoking within six months, but not within one month versus within one month. The researchers then randomly assigned the participants to an intervention group or a control group that did not receive the intervention.
Participants assigned to the control group received:
- A smoking cessation hotline number that offered free nicotine replacement therapy
- A list of practice resources and “Aim for a healthy weight ” booklet from the National Heart, Lung, and Blood Institute
- Quarterly health information newsletters
Participants enrolled in the intervention group who reported that they were not ready to quit smoking within 1 month participated in a 4-week motivation enhancement group designed to increase their motivation to quit smoking. Those who stated that they were ready to quit smoking within 1 month participated in a 7-week behavioral smoking cessation group. Participants could repeat groups as often as needed or move between groups if their willingness to quit smoking changed. Participants were offered smoking cessation medications regardless of their initial interest in quitting. Participants who successfully quit smoking and maintained abstinence from smoking for at least 1 week attended ongoing relapse prevention groups and were encouraged to continue using smoking cessation medications.
During the behavioral intervention, the participants were offered:
- One 1-hour smoking cessation/weight management group session per week
- One 20-minute individual smoking cessation/weight management session per week
- Support for physical activity
- Text messages to support health behavior change
During group and individual smoking cessation/weight management sessions, researchers provided participants with content such as information on the benefits and methods of quitting smoking, help in identifying smoking triggers, and more. Participants in the intervention group also received access to group exercise classes and incentives for participating in the intervention, including a small monetary stipend for group attendance and medallions associated with achieving health milestones.
Participants in the intervention and control groups were measured for weight and abstinence from smoking (i.e. 7 consecutive days without smoking tobacco) 6, 12, 15 and 18 months after the start of the intervention. In addition to these measurements, after 18 months, the researchers measured the participants’ cardiovascular health, including their 10-year risk of a cardiovascular event and their cardiovascular risk factors such as systolic blood pressure, total cholesterol, diabetes status, triglyceride and fasting glucose levels.
What were the results of the intervention?
The researchers found that after 18 months, 26.4% of people in the intervention group had achieved abstinence from smoking compared to 5.7% of people in the control group. Participants in the intervention group were also more likely to achieve abstinence from smoking at 6, 12, and 15 months compared to the control group. The ability to achieve abstinence from smoking after 18 months was not significantly influenced by participants’ willingness to quit, psychiatric diagnosis, gender, or race.
Participants in the intervention group also had a 12.7% drop in their 10-year risk of a cardiovascular event, while that risk increased by 3.6% in the control group. No significant difference in weight change was observed between the control (-1.4 kg) and intervention (+0.2 kg) groups.
Why is learning important?
Study results suggest that providing extended smoking cessation support to people with SMI may be effective in reducing smoking and improving cardiovascular health – even if people say they are not ready to quit immediately. The researchers suggest that the availability of evidence-based smoking cessation programs in addition to medication and counseling to people with SMI could help reduce the disparity in smoking-related mortality between people with SMI and the general population.
Daumit, GL, Evins, AE, Cather, C., Dalcin, AT, Dickerson, FB, Miller, ER, III, Appel, LJ, Jerome, GJ, McCann, U., Ford, DE, Charleston, JB, Young, DR, Gennusa, JV, III, Goldsholl, S., Cook, C., Fink, T. and Wang, N.-Y. (2023). Effect of a smoking cessation intervention involving 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