REVIEW OF: Brown RA et al, JAMA Psychiatry 2021;78(8):839–847

STUDY TYPE: Randomized clinical trial

Adults with serious mental illness tend to smoke heavily and die at much younger ages than the general population. Smoking is forbidden in psychiatric hospitals, so patients become abstinent during their inpatient stays and usually manage their withdrawal symptoms with nicotine replacement therapy (NRT). However, most patients resume smoking soon after discharge. 

The authors of this study reasoned that the forced abstinence during patients’ hospital stays could jump-start efforts to promote smoking cessation after discharge. They compared usual care, consisting of NRT patches and smoking cessation information, with a systematic approach called sustained care. Its main components were 1) a motivational interviewing session, 2) free access to cessation counseling after discharge (phone, text, or web-based), 3) telephone counseling for three months, and 4) free NRT patches. 

This NIMH-funded study took place in a private psychiatric hospital in Austin, Texas. Adults who smoked more than five cigarettes a day were randomized to usual care (n=173) or sustained care (n=169). All subjects smoked an average of 17 cigarettes per day at baseline. The most common discharge diagnoses were depression, substance-related disorders, bipolar disorder, and schizophrenia. Hospital length of stay averaged six days. Two-thirds of subjects were economically disadvantaged (defined as household annual income <$25,000)—a factor that, in addition to serious mental illness, contributes to low rates of success in achieving smoking cessation.

The main outcome measure was smoking abstinence for the past seven days, verified by salivary cotinine analysis. Since the use of nicotine products results in elevated cotinine levels, exhaled carbon monoxide was measured in subjects who reported recent NRT use. Subjects were followed at one, three, and six months post-discharge and their use of smoking cessation treatments (eg, counseling, NRT, bupropion, varenicline) was recorded. 

The sustained care group was significantly more likely to be abstinent than the usual care group at six months (8.9% and 3.5%, respectively; p=0.01). The sustained care group was also significantly more likely (75% vs 41%; p=<0.001) to use smoking cessation treatments in the six months following discharge.

CARLAT TAKE

This intervention shows that adults with serious mental illness can be successfully engaged in smoking cessation treatment following hospital discharge. Though only a small proportion of patients receiving sustained care achieved abstinence, it was substantially higher than the proportion of patients who did not participate in the post-discharge program. Given the significantly shorter life expectancy of patients who smoke, such a program deserves wider ­application.