1. Alive and Kicking the Habit: Smoking Cessation and Mental Illness Jeanette Waxmonsky, Ph.D., Chad D. Morris, Ph.D., Mandy Graves, M.P.H., Alexis Giese, M.D., Olga Belikova University of Colorado at Denver and Health Sciences Center Introduction Persons with mental illnesses represent approximately 7% of the U.S. population but consume over 30% of cigarettes and comprise 44% of the entire U.S. tobacco market (1). Smoking rates vary greatly by psychiatric diagnosis (2,3), e.g. persons with schizophrenia smoke at rates over 60% compared to approximately 50% of those with schizoaffective or bipolar disorder, and smoking is associated with higher rates of alcohol and drug use (2). These persons experience greater physical comorbidities and deaths compared with the general population, increased psychiatric symptoms, hospitalizations, and need higher medications dosages (4-7). Quit rates for persons with mental illnesses are less than the general population, but smoking cessation rates are still substantial (1,8). Although past study findings have been encouraging, this population faces significant barriers to accessing effective interventions. Current cessation approaches for the general population are not specifically tailored to this population’s unique characteristics. This pilot project was designed to test tobacco cessation interventions in the public mental health system. It is a collaboration between the University of Colorado at Denver and Health Sciences Center, Department of Psychiatry, the Colorado Department of Public Health and Environment, the Colorado QuitLine, and Community Mental Health Centers. Results Preliminary results from repeated measures analyses using SAS 9.1 Proc Mixed compared baseline to 3 month data on all available data (without imputation) across all three groups and showed a significant decrease in self-reported average number of cigarettes smoked per day across all three groups, F(3,83)=3.77, p>.0002. However, carbon monoxide (CO) readings comparing baseline to 3 month data across groups were not significant, and this may be related to missing carbon monoxide data for participants at baseline (38% missing data; baseline CO readings were not collected at one clinic site). Scores on the HAM-D and BPRS showed a significant decrease in depressive and psychotic symptoms respectively over time for all groups (p<.01) but did not differ across groups. Similarly, at 3 months, all three groups had significantly lower rates of tobacco dependence from baseline as measured by the Fagerstrom test (p<.01), but did not differ across groups. At 3 months, 41% of Group 1 participants, 10% of Group 2 participants, and 32% of Group 3 participants were lost to follow up. (Many of these were unreachable by telephone at 3 months). References 1.Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and Mental Illness: A Population-Based Prevalence Study. JAMA 2000;284(20):2606-2610. 2.Morris CD, Giese AA, Turnbull JJ, Dickinson M, Johnson-Nagel N. Predictors of Tobacco Use Among Persons With Mental Illnesses in a Statewide Population. Psychiatr Serv 2006;57(7):1035-1038. 3.Hughes JR, Hatsukami DK, Mitchell JE, Dahlgren LA. Prevalence of smoking among psychiatric outpatients. American Journal of Psychiatry. 1986;143(8):993-7. 4.Brown S, Inskip H, Barraclough B. Causes of the excess mortality of schizophrenia. Br J Psychiatry 2000;177:212-7.7. 5.Joukamaa M, Heliovaara M, Knekt P, Aromaa A, Raitasalo R, Lehtinen V. Mental disorders and cause-specific mortality. Br J Psychiatry 2001;179(6):498-502. 6.Desai HD, Seabolt J, Jann MW. Smoking in patients receiving psychotropic medications: a pharmacokinetic perspective. CNS Drugs 2001;15(6):469-94. 7.Goff DC, Henderson DC, Amico E. Cigarette smoking in schizophrenia: relationship to psychopathology and medication side effects. Am J Psychiatry 1992;149(9):1189-94. 8.Baker A, Richmond R, Haile M, Lewin T, Carr V, Taylor R, et al. A Randomized controlled trial of a smoking cessation intervention among people with a psychotic disorder. Am J Psychiatry 2006;163(11):1934- 42. Acknowledgements This research was supported by funding through the Colorado Department of Public Health and Environment, State Tobacco Education and Prevention Partnership. Acknowledgements This research was supported by funding through the Colorado Department of Public Health and Environment, State Tobacco Education and Prevention Partnership. Contact Information Jeanette Waxmonsky University of Colorado at Denver and Health Sciences Center 4455 East 12 th Ave, A011-11 Denver, Colorado, 80220, USA Jeanette.Waxmonsky@uchsc.edu Contact Information Jeanette Waxmonsky University of Colorado at Denver and Health Sciences Center 4455 East 12 th Ave, A011-11 Denver, Colorado, 80220, USA Jeanette.Waxmonsky@uchsc.edu Discussion These preliminary analyses show a significant reduction in self-reported number of cigarettes smoked per day (a reduction of about 6 cigarettes) and a reduction in tobacco dependence across all three cessation interventions. Also, all three groups showed a significant reduction in depressive and psychotic symptoms. At 3 months, there were no differences among those who received the Quitline intervention only (Groups 1 & 3) at this time period and those who received the QuitLine intervention and Wellness Group intervention simultaneously (Group 2). Interestingly, participants in Group 2 had the lowest lost-to-follow up rate at 3 months, which may suggest that this more intensive, two-pronged intervention allows for better engagement with persons with mental illnesses who are attempting to quit or cut down on smoking. There are several limitations to these initial findings. At 3 months, Group 3 had only received the QuitLine Intervention and had not yet started the Wellness Group Intervention. Also, we did not complete baseline data for CO monitor readings for one clinic site, which may have affected our initial comparison to 3 month data. In future analyses, we will examine 6- and 12-month CO monitor data to determine if there is a significant decrease in CO levels over time. Also, since many smoking studies treat study dropout as continued smoking, in our final analyses we will impute smoking values for dropouts (last known value carried forward). Given the current differential effect of dropouts for the three groups, it appears the Group 2 (QuitLine and Wellness Group combined) may yield a greater tobacco reduction and cessation rate for this population. Figure 1: Tobacco Cessation Pilot Study Intervention Timeline Table 3: Demographic Data Methods Participants were recruited from one of four Community Mental Health Centers (CMHC). Eligible participants were regular smokers that were ≥ 18 years old, cognitively able to provide informed consent and participate in educational groups, and English-speaking. Individuals were excluded if experiencing severe psychiatric symptoms or active substance abuse. Mental health providers at the CMHC assessed patients’ appropriateness for participation. The pilot study is an ongoing randomized controlled trial, with randomization at the patient level for each of the four CMHC pilot sites to one of three interventions (Figure 1). At each CMHC, Group 1 received National Jewish Quitline Services. Group 2 received QuitLine services plus a 10 week Tobacco Cessation Wellness Group. Group 3 received QuitLine services plus a delayed start (3 month) Wellness Group. This staggered design allowed control data to be collected on participants randomized to the later starting group. Trained center/clinic staff conducted these psychoeducational wellness groups (Table 1). The study assessment battery was collected at baseline and 3 month time points, and will continue to be collected at 6 months and 12 months (see Table 2). The primary outcome variables are self-reported smoking (cigarettes per day in the last 7 days) and CO monitor readings (an objective measure of cigarette use). Primary Hypotheses: (1) In comparison to treatment as usual, brief assessment and referral to the National Jewish Quitline will significantly increase tobacco cessation rates and reduce daily cigarette consumption, and; (2) In comparison to treatment as usual and to brief assessment and referral to the National Jewish Quitline (intervention #1), participants who also receive brief assessment and referral to the National Jewish Quitline and participate in a community Wellness Group (intervention #2) will have significantly higher tobacco cessation rates and reductions of daily cigarette consumption. Table 1: Wellness Group Sessions Session 1 Introduction to the program Session 2 Working with the positives (strengths) Session 3 How smoking affects your body Session 4 Building self-confidence Session 5 Dealing with stress and building supportive relationships Session 6 Healthy ways of dealing with feeling down Session 7 Dealing with strong negative feelings Session 8 Diet and exercise Session 9 Planning for high-risk situations Session 10 Celebrating the road to recovery Table 2: Study Assessments Table 4: Preliminary Outcomes