Short CommunicationStage movement following a 5A's intervention in tobacco dependent individuals with serious mental illness (SMI)
Research Highlights
► Individuals with serious mental illness (SMI) continue to smoke at alarming rates. ► Cessation rates are low and interventions are under-utilized in this population. ► A psychiatrist-delivered, brief intervention can positively impact smokers with SMI. ► SMI smokers move through the process of change in similar ways to other smokers. ► As with non SMI smokers success comes after multiple attempts, relapse, and recycling.
Introduction
Individuals with serious mental illness (SMI) continue to smoke at alarming rates, with prevalence rates as high as 90% among individuals with schizophrenia (de Leon et al., 1995, Williams and Ziedonis, 2004), compared to smoking rates of only 20–25% in the general population. Moreover, Kelly and McCreadie (1999) found that more than two-thirds of smokers with schizophrenia smoked 25 or more cigarettes daily compared to only 11% in the general population. Smokers with psychiatric illnesses and substance abuse disorders are estimated to consume about 44% of cigarettes smoked in the United States (Lasser et al., 2000), which may lead to approximately 200,000 deaths per year (Williams & Ziedonis, 2004).
Cessation rates are low in this population, interventions are under-utilized, and encouragement to quit is infrequent, even by health professionals (Addington, 1998). Despite lower cessation rates, over half of the SMI smokers want to quit (Forchuk et al., 2002). Increasing motivation to quit is a key element for successful cessation (DiClemente et al., 2004, DiClemente et al., 1991) and essential to protect the health of this vulnerable population. A best-practice, brief intervention designed to increase motivation to change smoking behavior involves having health care providers Ask, Advise, Assess, Assist and Arrange for follow-up for all smokers (5A's) in healthcare settings (Fiore et al., 2008). One of the few studies to evaluate efficacy of the 5A's with SMI smokers examined physician-delivered 5A's in public mental health clinics and reported modest effects of the 5A's for reducing tobacco use and increasing cessation rates 12 months after the intervention phase (Dixon et al., 2009). Specifically, the number of individuals who reported smoking in the past seven days and the number of cigarettes typically smoked in a week differed significantly, but abstinence confirmed by CO ppm < 10 did not. These modest changes are significant since the intervention was low-impact and patients were not chosen based on readiness to change. In addition, by implementing the intervention with most of their patients who smoked, psychiatrists demonstrated the acceptability and feasibility of integrating 5A's, or at least 3A's (Ask, Advise, and Assess) into treatment.
Stages and other process of change variables from the Transtheoretical Model of Behavior Change (TTM) have predicted the likelihood of quit attempts and cessation outcomes (DiClemente et al., 1991) and could be related to progress toward cessation in SMI smokers as well. Theoretically, smokers in more advanced stages (i.e., Contemplation or Preparation) would be more likely than those in Precontemplation to quit smoking. Processes of change, engaging in appropriate coping activities at the right time, decisional considerations and both self-efficacy and temptation to smoke are also related to the probability of cessation success. Specifically, in the early stages, such as Contemplation and Preparation, experiential processes appear more salient with behavioral processes usually increasing in later action stages (DiClemente, 2003). In addition, when quitting an addictive behavior, it is generally expected that abstinence self-efficacy would increase and levels of temptation drop (Velicer, DiClemente, Rossi, & Prochaska, 1990).
This study examined how changes in stage status and how other process dimensions (coping processes of change, abstinence self-efficacy, temptation to smoke as well as the pros and cons of smoking) were associated with changes in stage transitions over time for individuals with SMI. We evaluated stage of change transitions over time among a sample of SMI smokers who had participated in a larger study examining a provider-based implementation of the 5A's for the smoking cessation intervention during their outpatient psychiatric care (Dixon et al., 2009). The study examined how stage transitions were related to process of change variables.
Section snippets
Study setting and sample
This study analyzed data from a subsample of the original 304 smokers who were in treatment at six community mental health centers in the greater Baltimore area, had a diagnosis of schizophrenia or other psychotic illness, and had participated in the original study. The subsample for analyses included only participants who were assessed at baseline, 6 months and 12 months and who had complete baseline data for stages of change (n = 110). A full description of the sample, methodology, and smoking
Description of sample
The analysis sample (n = 110) was balanced with respect to gender (53, 48.2% male; 57, 51.8% female) and race (49, 44% White; 54, 49% African-American; 7, 6% other) with a mean age of 44.1 (SD = 6.2) years. Three-quarters of these SMI smokers were diagnosed with schizophrenia (n = 81); the remainder (26%) with affective psychoses. Most (81%) had been smoking for over 20 years and began smoking on average at 15.3 (SD = 5.9) years of age. As required by eligibility criteria, all participants had smoked in
Discussion
Stage of change transitions for SMI smokers over the one year follow-up indicated variable patterns of movement through the stages of change as reported in prior studies of smoking (Kohler et al., 2008, Martin et al., 1996, Prochaska et al., 1991) and other behaviors (Feldman et al., 2000). Although movement into the action stage and abstinence at one year was modest (6.4%) during this low intensity intervention, it is on par with self-change success estimates (Cohen et al., 1989). Although SMI
Role of Funding Sources
This work was supported by Grant R01DA14393 from the National Institutes of Drug Abuse (NIDA), Bethesda, MD (Dr. Dixon). NIDA had no role in the study design, collection, analysis or interpretation of the data, writing the manuscript, or the decision to submit the paper for publication.
Contributors
Author DiClemente participated in study design and execution and writing and revision of the manuscript. Author Delahanty designed and completed the statistical analyses, composed the methods and results sections of the manuscript, and participated in reviewing the manuscript. Author Garay Kofeldt conducted literature searches and participated in writing and reviewing the manuscript. Dr. Dixon is the Principal Investigator of the parent study and Drs. Dixon, Goldberg, and Lucksted participated
Conflict of Interest
All authors declare that they have no conflicts of interest.
References (20)
- et al.
Correlates of transitions in stage of change for quitting among adolescent smokers
Addictive Behaviors
(2008) - et al.
Latent transition analysis to the stages of change for smoking cessation
Addictive Behaviors
(1996) - et al.
Relapse situations and self-efficacy: An integrative model
Addictive Behaviors
(1990) - et al.
Addressing tobacco among individuals with a mental illness or an addiction
Addictive Behaviors
(2004) Group treatment for smoking cessation among persons with schizophrenia
Psychiatric Services (Washington, D.C.)
(1998)- et al.
Debunking myths about self-quitting: Evidence from 10 prospective studies of persons who attempt to quit smoking by themselves
The American Psychologist
(1989) - et al.
Schizophrenia and smoking: An epidemiological survey in a state hospital
The American Journal of Psychiatry
(1995) Addiction and change: How addictions develop and addicted people recover
(2003)- et al.
The process of smoking cessation: An analysis of precontemplation, contemplation and preparation stages of change
Journal of Consulting and Clinical Psychology
(1991) - et al.
Readiness and stages of change in addiction treatment
The American Journal on Addictions
(2004)
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