Arc

Smoking Cessation andSerious Mental Illness

Marsha Snyder, Judith McDevitt, and Susan Painter

hives of Psyc

A focus group methodology was employed to identify personal, social, andenvironmental factors that affect smoking cessation in persons with seriousmental illness. Four focus groups were held: two for those who had attemptedto quit smoking and two for those who had never attempted to quit. Smokingis central to daily survival in patients with serious mental illness. Social andenvironmental reinforcement can both assist and hinder efforts to stopsmoking. Smoke-free environments influence decisions to quit smoking ifpositive social comparisons with nonsmokers occur. Peer modeling and in-terpersonal connections with nonsmokers can offer links to forming suppor-tive nonsmoking relationships.D 2008 Elsevier Inc. All rights reserved.

From the College of Nursing, University of Illinois atChicago, Chicago, IL.

Corresponding Author: Marsha Snyder, PhD, APRN,CNS, Department of Public Health, Mental Health, andAdministrative Nursing, University of Illinois at Chicago,845 South Damen Avenue, Chicago, IL 60612-7350.

E-mail address: snyderm@uic.edun 2008 Elsevier Inc. All rights reserved.0883-9417/1801-0005$34.00/0doi:10.1016/j.apnu.2007.08.007

P EOPLE WHO SUFFER from serious mentalillness (SMI) may carry a diagnosis of

schizophrenia, bipolar illness, severe forms ofmajor depression, obsessive–compulsive disorder,and/or panic disorder (U.S. Department of Healthand Human Services [USDHHS], 2005a, 2005b).Persons with SMI experience high mortality ratesrelated to diabetes and cardiovascular diseasewhen compared with the general population(Brown, Barraclough, & Inskip, 2000; Brown,Britwistle, Roe, & Thompson, 1999; Felker, Yazel,& Short, 1996). These individuals are two to threetimes more likely to smoke compared with personsin the general population (Lasser et al., 2000). Forpersons in the general population who are between15 and 54 years old, there is a 24% lifetime preva-lence for nicotine dependence (Breslau, Johnson,Hiripi, & Kessler, 2001). Although estimates vary,smoking prevalence ranges from 22.5% for personswithout mental illness to 34.8% for those who haveexperienced a mental illness within their lifetime(Lasser et al., 2000).

Smoking increases risk for chronic diseases—among them, cancer, heart disease, stroke, andrespiratory disease (Centers for Disease Control andPrevention, 2007). In addition to the effects oftobacco smoking, many highly effective and

hiatric Nursing, Vol. 22, No. 5 (October), 200

commonly used psychiatric medications are asso-ciated with weight gain, further increasing healthrisks for hypertension and heart disease (Green,Patel, Goisman, Allison, & Blackburn, 2000).Moreover, persons with SMI who are heavysmokers as defined by the Fagerstrom ToleranceQuestionnaire (Fagerstrom, 1978) report that theyexperience increased positive symptoms (halluci-nations, delusions, and disorganized thoughts andspeech) and need more medication to relieve thesesymptoms. To combat the effects of excessmedication, these smokers use cigarettes as astrategy to reduce negative symptoms (affectiveflattening, avolition, apathy, and anhedonia; For-chuk et al., 2002; Ziedonis, Williams, & Smelson,2003). In addition, persons with schizophreniareport improved cognitive function as well as

8: pp 297–304 297

298 SNYDER, MCDEVITT, AND PAINTER

decreased anxiety and depression as benefits oftheir nicotine use (George et al., 2002; Lucksted,Dixon, & Sembly, 2000). Given the higher rates ofsmoking among persons with SMI, these positiveeffects appear to outweigh any of the negative long-term health effects or concerns about medicationadjustments that may be needed to managetheir SMI.

Persons with SMI have great difficulty withtobacco use cessation (Addington, el-Gurbaly,Campbell, Hodgins, & Addington, 1998; Ziedonis& Williams, 2003). In one study, persons whoexperience nonaffective psychosis reported a 0%quit rate, in contrast to the 42.5% self-reported quitrate of smokers without any history of mentalillness and to the 37.1% quit rate for smokers withany history of mental illness (Lasser et al., 2000).Low quit rates in schizophrenia are associated withan autosomal dominant pattern of inheritance thatsuggests a direct relationship between the patho-genesis of schizophrenia and nicotine dependence(Freedman, Leonard, & Gault, 2001; Ziedonis &Williams, 2003).

Similar to persons in the general population,persons with SMI who smoke often also use alcohol(USDHHS, 2005a, 2005b). The reinforcing effects ofnicotine seem to be greater for smokers who usealcohol (Hughes, Rose,&Callas, 2000). Clinicians areencouraged to use the “five As” (ask, advise, assess,assist, and arrange follow-up) with every tobacco userwho is willing to quit (Fiore et al., 2000). Although thefive As intervention has been effective in primary caresettings, it unfortunately has been found to beineffective for persons experiencing behavioral pro-blems or dual disorders (Krejci&Foulds, 2003).Otherapproaches may be needed for persons with SMI tosuccessfully quit smoking.

Studies of persons with SMI and their efforts toquit smoking or remain smoke free are limited. In aquit smoking program for 10 highly nicotine-dependent persons with SMI, poor physical healthand commitment to quitting were reported motiva-tors for smoking cessation. Seven of the 10participants completed the program, with 1 of the7 participants remaining smoke free after 4 months.Barriers identified by these subjects included lackof nonsmoking coping skills, smoker identity,tobacco product accessibility, withdrawal, andlimited nonsmoking social support (Van Dongen,Kriz, Fox, & Haque, 1999). In another study, theperceived advantages and disadvantages of tobacco

smoking and quitting among 40 clients in apsychosocial rehabilitation program were exploredin five focus groups (Lucksted et al., 2000).Gaining commitment to quitting and maintainingthis commitment were the major hurdles reportedby the persons in these focus groups.

Five pharmacotherapies (sustained-releasebupropion hydrochloride, nicotine gum, nicotineinhaler, nicotine nasal spray, and nicotine patch) areidentified as first-line treatments for smokingcessation (Fiore et al., 2000). Use of these first-line treatments offers help to approximately 30% ofsmokers in the general population, with anincreased success rate with the addition of psycho-social treatments (Ziedonis & Williams, 2003).Even with the best intentions, however, mostsmokers in the general population require severalattempts before fully quitting smoking (Rigotti,2002). The effective use of nicotine replacement forsmokers with schizophrenia is unclear at this time.

Although persons with SMI may be aware of thehealth risks associated with smoking and have adesire to quit, it appears that the perceived benefitsof quitting do not always outweigh the barriers toquitting. Intervention strategies designed for thegeneral population may be less effective for personswith SMI. The experience of quitting is unique toeach person and seems to be shaped by expectationsand explanations attributed to the experience(Gilbert & Warburton, 2003; Lawn, Pols, & Barber,2001; Stoffelmayr, Wadland, & Pan, 2003). For thisreason, tailoring interventions to address theseunique expectations might increase their effective-ness. The purpose of this study was to identifypersonal, social, and environmental factors thataffect smoking cessation and motivators for personswith SMI who are undergoing community-basedpsychiatric rehabilitation.

METHODS

This study used a qualitative exploratorydesign with focus group methods to collectdata (Krueger, 1998).

Sample and Setting

Participants included clients of two psychiatricrehabilitation centers located in a Midwestern cityin the United States. The participants (N = 25)included 19 men and 6 women between 24 and 55years old who were (1) willing to discuss theirviews in a focus group; (2) nicotine dependent, with

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a score of at least 6 on the Fagerstrom NicotineTolerance Scale (Fagerstrom, 1978); and (3) able toachieve a score of 25 or higher on the Mini MentalState Examination (Folstein, Folstein, & McHugh,1975). Two focus groups were held at eachrehabilitation center: a focus group for smokerswho were nicotine dependent and not attempting toquit and another for nicotine-dependent smokerswho had attempted to quit during the past year.Center A (n = 9), a mental illness and substanceabuse residential program for persons with dualdiagnosis, provided case management and rehabi-litation services to predominantly middle-aged low-income African American and Caucasian adults.Center B (n = 16), a clubhouse, offered vocationalrehabilitation and employment services for pre-dominantly middle-aged low-income AfricanAmerican adults with SMI. As shown in Table 1,more men than women participated in the focusgroups; in addition, whereas men from both sitesreported starting to smoke by age 12 years, mostwomen from both sites did not begin to smoke untilafter they completed high school.

Procedures

The institutional review boards of the universityand the psychiatric rehabilitation agency approvedthe study. Potential participants were recruitedthrough the principal investigator's announcementof the study at client council meetings and otherregular informational group sessions held at each ofthe program sites. The principal investigatorscreened interested clients at each site for eligibility.Each potential participant gave informed consentwith answers to any questions provided before thescreening process. Those who met eligibilitycriteria and provided written consent to participatewere given a date for participation in either theattempted-to-quit focus group or the never-

Table 1. Smoking Cessation in Adults Between 25 and 55 Years Old WiSex, Quit Status, an

Women

Recruited (n = 11) Participated (n =

Center ATried to quit 3 1

Never tried 2 1

Center BTried to quit 5 3

Never tried 1 1

Total 11 6

attempted focus group scheduled at their programsite. Before each focus group began, participantswere again informed about the study. Participantsreceived a nutritious snack and $10 at the end ofeach focus group session.

Data Collection

Focus groups as a research strategy can offerparticipants the opportunity to express their con-cerns about living with an SMI and how thisimpacts their lives, at the same time enabling themto identify what they consider to be the bestapproaches to smoking cessation. When placed in aone-on-one interview situation, persons with SMImay become overanxious and unable to respond toquestions, whereas the dynamic nature of a focusgroup may afford safety in numbers and stimulatedialogue. Focus groups can provide unique infor-mation and enhance understanding of preferencesand perceived barriers to motivation, providing thebasis for design, implementation, and evaluation oftailored interventions (Greenbaum, 2000).

An advanced practice nurse with extensiveexperience conducting groups moderated the dis-cussions. Audiotapes of the sessions were tran-scribed verbatim by an experienced transcriber. Thediscussions were semistructured and used an inter-view guide based on a previous focus group studyto identify barriers to and enablers of physicalactivity in persons with SMI (McDevitt, Snyder,Miller, & Wilbur, 2006) and in urban women(Wilbur, Chandler, Dancy, Choi, & Plonczynski,2000). Modified for the present study, the guideincluded questions that addressed attitudes andbeliefs related to smoking and smoking cessation aswell as personal, social, and environmental moti-vators for smoking and smoking cessation. Asample of the items is presented in Table 2. At thebeginning of each session, the moderator empha-

th SMI: Focus Group Participant Recruitment and Participation byd Study Site

Men

6) Recruited (n = 22) Participated (n = 19)

3 35 4

5 59 722 19

Table 2. Focus Group Interview Guide

A. Think about the ways in which you distinguish betweensmokers and nonsmokers.

B. Let's talk a little about where you live and how you spendyour time.

C. Think about how you feel about smoking and not smoking.D. If you have tried to quit smoking, what services did you use?

Satisfaction with these?

300 SNYDER, MCDEVITT, AND PAINTER

sized that all points of view were important andvaluable. Quiet participants were encouraged tocomment when they felt comfortable.

Data Analysis

Analysis of the transcripts was an iterativeprocess whereby the investigators reviewed eachother's interpretations of themes presented (Krue-ger, 1997). Transcripts were read and reread, andsummary tables of responses to focus groupquestions identifying key ideas, themes, andquotations were prepared. A set of code words forthe ideas and themes was entered into QSRNUD*IST N4 qualitative software. Each transcriptwas analyzed by two of the investigators, who laterworked independently, read each transcript, andassigned code words to blocks of text and then metto review the results. This repeated process offeredopportunity to confirm codes, group them intothemes and concepts, and then reach a finalconsensus on interpretation of the data.

RESULTS

Eleven women and 22 men were recruited fromthe participating rehabilitation centers. Of these, 6women and 19 men (75%) participated in the focusgroups. As shown in Table 1, the two groups ofpersons who tried to quit in the past included 4women and 8 men (n = 12) and the two groups ofpersons who never attempted to quit included 2women and 11 men (n = 13). Although recruitmentfrom both centers was equal, participation fromCenter A, the mental illness and substance abuseprogram, was lower than that from Center B. Eachgroup session lasted approximately 45 minutes.Those participants who had made attempts to quitsmoking reported using nicotine replacement,primarily patch and gum, without success. Thekey ideas and themes related to personal, social,and environmental factors that participantsreported regarding smoking and nonsmoking arepresented subsequently.

Personal Factors

Personal factors included themes related toparticipants' confidence to quit smoking, smokingas a mechanism for coping with everyday lifestressors, and expectations for how life would bewithout smoking.

Confidence to Quit Smoking

Persons who never tried to quit and those whohad made at least one attempt reported that feelingthe desire to smoke overshadowed any effort atquitting; for example, one participant stated, “I wasnever able to quit for longer than a few weeks. Allthree times I quit I really didn't have a desire toquit.” The hopelessness extended to attempts atusing smoking cessation methods. As one partici-pant reported, “I tried the Nicorette gum and patchbut I smoked anyway. I didn't try anything else”;another stated, “I tried cold turkey, the plasticcigarette, tried the patch, and none of it worked; theonly thing I didn't try was hypnosis.” Someparticipants indicated that they would need anotherperson with them continuously to stop them fromtaking a smoke: “I would need to drag my momma,my grandmother, everybody, even my dog, toencourage me not to smoke.”

Despite their lack of confidence in being able toquit, some smokers reported that having the abilityto choose whether to smoke or not to smoke wasvery important. As one participant related, “I didquit for a few days, and that makes me a person[who] chooses; nobody is forcing me.” Othersmokers reported a sense of hopelessness regardingloss of autonomy to cigarettes in which the abilityto choose was taken away in response to theiraddiction. Comments included the following: “Youchoose to just keep on smoking”; “It would take areal tragedy to happen for me to stop”; and “I needsomething to knock it out of my mind completely.”

Coping With Life Stress

Participants reported that smoking cigaretteswas a central part of everyday life and in somecases “a good friend.” One participant reported, “Iwouldn't know how not to smoke. I can't rememberwhat it was like without smoking.” They reportedusing cigarettes to cope with depression, anxiety,boredom, and loneliness. Consistent with theliterature about the benefits of smoking for personswith SMI, the higher the anxiety or depression, the

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more the participants reported they smoked. Cigar-ettes were viewed as a necessary “affordableluxury.” Although participants felt disappointed inthemselves when they would choose to spendmoney on cigarettes rather than on food, they alsofelt rich since they could indulge themselves andbuy this one luxury item.

Once I was in the hospital and I didn't smoke for 8 days. Ifelt good. A couple [of] hours after leaving, my case workeroffered me some money, and then it snapped in my head,‘I'm gonna buy some cigarettes.’ I didn't have anything elseto fall back on. There wasn't anything else affordable.

Outcome Expectations for Life Without Cigarettes

Across all groups, participants indicated thatthey did not believe they could achieve the level ofpleasure and satisfaction received from smokingfrom any other activity. Several participantsindicated that not smoking would mean “havingnothing to look forward to.” Those who had nevermade an attempt had difficulty considering whatthey would gain by quitting. A number ofparticipants either were able to find health benefitsin smoking (e.g., “…tobacco is being found helpfulin certain areas…”) or minimized the effect ofsmoking on health. As one participant reported, “Ihave a friend who doesn't smoke or drink, yet hecoughs and coughs. He's a young guy, so I know itisn't just the smoking.”

Those who had made attempts to quit associatednonsmokers' ability to not smoke with suchsuccesses in life as being able to “hold jobs, go toschool, and look and act healthy.” As one smokerreported, “A nonsmoker has a better chance offulfilling his dreams and shows strength I don'thave.” Another person reported observing non-smokers as having “deeper concentration since theydon't have to stop and have a cigarette.”

Reinforcement Factors

Participants discussed social and environmentalfactors in relation to how these provided reinforce-ment either for smoking or for not smoking.

Social

Participants reported verbal and nonverbal feed-back from both smokers and nonsmokers related totheir smoking. The feedback provided reinforce-ment for smoking and reinforcement for notsmoking and may have been dependent on a

participant's readiness for change with respect tosmoking cessation. Smokers who had never madean attempt to quit reported feeling harassed bynonsmokers and observed that nonsmokers areoverweight, “eat lots of sweets,” and look sad ordepressed, whereas “smokers have more fun.” Incontrast, smokers who had made attempts to quitviewed nonsmokers as having “deeper conversa-tions and using conversation as a tool insteadof smoking.”

The participants reported that the smokers theyknew hung around other smokers and that thesmoking tended to isolate them from nonsmokers:“Yea, 90% of the people in this building smoke.”As participants indicated, “Nonsmokers don't talkto you because you smoke” and “I can't say Iknow any nonsmokers I would be hangingaround with.” On the other hand, smokingactivities offered reliable opportunities for socialinteraction to these persons with SMI. As anotherparticipant reported,

Smoking is a crutch for people being lonely. Begging forcigarettes gets you connected. You get introduced, and itdraws attention to you. It helps you get to know people. It'slike some kind of security.

Group pressure affects whether people choose tosmoke or not smoke; as reflected by one participant,

I think the government is trying to change the majority tothe minority, and when you have the majority of peopledoing a certain thing, you're gonna choose to go with themajority. I think that's how it starts. If the majority of youguys didn't smoke cigarettes, I probably would not smoke. Iwould go with the majority.

Environmental

Aspects of the environment that support a choiceto not smoke included program structure, whichcould provide the opportunity to work or be busyand thus not smoke. For example, one participantsaid, “When I'm sitting around doing nothing, Ismoke more; it fills the time”; another observed,“When I'm working, I'm busy and not smoking.”However, program structure did not always supportchoosing not to smoke. One participant reflected,“When I was working, I smoked more since youcould take as many smoke breaks as you wanted, sothose [who] smoked took a lot of breaks.”

The influence of social environment also playedan important role in smoking behavior. One

302 SNYDER, MCDEVITT, AND PAINTER

participant reported, “It is interesting to me that Iam able to not smoke for several weeks when I stayat my mom's house, but the minute I am back in myapartment, I light up.” Participants in all groupsreflected on smoking limits that either family orfriends enforced: “When I visit my brother, I smokein the basement” and “You'd be surprised at howmany people will not allow smoking in their cars.”Some participants indicated that they would some-times try to bend the rules but that, out of respect forthe nonsmokers, they would probably stick to therules. Some environments stimulated participants tocreate rules for themselves: “A lot of times werecognize we don't need to smoke, like at church.We give respect to the place.”

DISCUSSION

The focus group methodology was well suited tothis study on smoking cessation and SMI, and thefocus group format was useful in engaging personswith SMI in a discussion regarding an activity thatthey held very close to their hearts and minds.However, more persons were recruited for thegroups than those who actually participated,possibly due to their uncertainty about the purposeof the groups. Those who did attend were anxiousabout coming into the group; as some indicated,“Are you going to make us quit?” The purpose ofthe focus group and parameters of the informedconsent had to be repeated several times to reassureparticipants. Once the sessions started, groupparticipants relaxed and were very verbal. Informa-tion shared in the groups provided insight on theperspectives of smoking and quitting from personswith SMI themselves.

Similar to the findings of Lucksted et al. (2000)and Van Dongen et al. (1999), many of the focusgroup participants started smoking in their teensand indicated that smoking was central to theircoping with the stress and boredom of everydaylife. For many, smoking was seen as their one solepleasure. Some participants related that smokingafforded them increased ability to concentrate andenabled them to interact socially, a finding alsoreported elsewhere (Lucksted et al., 2000; VanDongen et al., 1999). Although findings in additionto these predictable findings must be consideredtentative, motivators for smoking or stoppingsmoking repeatedly voiced by these participantsincluded the influence of nonsmokers and non-smoking environments on their smoking behavior.

Choosing to not smoke in response to social orenvironmental pressure increased these partici-pants' sense of autonomy.

Recommendations for Practice and Research

Recommendations for practice and researchaddress issues surrounding decisional control andthe influence of role models and smoke-freeenvironments. The smokers who participated inthe focus groups indicated that having the auton-omy to decide to smoke or not to smoke was veryimportant to them. To stop smoking requiressignificant cognitive and behavioral change.Change is difficult for everyone and is thought tooccur in discrete stages: precontemplation, con-templation, action, and maintenance. Movementthrough these stages is modulated through adecisional balance between positive outcome andnegative outcome evaluations (Prochaska, DiCle-mente, & Norcross, 1992; Velicer, Norman, Fava,& Prochaska, 1999). Helping persons with SMIwith this decisional balance through a process ofweighing the pros and cons offers opportunity forfreedom as well as responsibility. Assisting smo-kers with SMI to recognize the consequences oftheir smoking or not smoking could advance theirability to self-manage their smoking behavior aswell as their mental illness. The Evidence-BasedPractices implementation toolkit for Illness Man-agement and Recovery addresses both building asocial support network and coping with stress(USDHHS, 2005a, 2005b). The toolkit offerspersons with SMI strategies for illness managementthrough a comprehensive, structured, and step-by-step program. Integration of the toolkit with worktoward smoking cessation can highlight the inter-relatedness of recovery from both smoking andSMI. Further investigation and identification ofstrategies that promote self-management of mentalillness as well as addictive behaviors for personswith SMI are needed.

Nonsmokers may play a pivotal role in thechange process for smokers with SMI. Whereassome participants indicated that life without smok-ing would be empty, others viewed the life ofnonsmokers with yearning. It is difficult to enactany change in behavior if there is no role model forthe new behavior. Bandura (1982) maintained thatalthough much learning occurs in direct experience,it can also be acquired through observation ofothers' behavior. Observation and imitation of

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persons who smokers deem worthy in relation tovalues, attitudes, beliefs, and behavior can provideeffective modeling. For smokers who have limitedcontact with nonsmokers, participation in a supportgroup for nonsmokers may provide a forum whereincreased motivation needed to stop smoking couldbe developed. Another possible strategy would be topair smokers who are motivated to quit withnonsmokers who through modeling could providethe smokers with the opportunity to learn socialskills and coping strategies for nonsmoking.

Social networks and environmental structure canboth support and hinder smokers' efforts towardsmoking behavior change. Smokers in the focusgroups indicated they smoked less when the envi-ronment limited their access to smoking. However,most continued to smoke once they left theseenvironments. Enforcing nonsmoking environ-ments is one way to tip the decisional balance.Smoke-free mandates can create environments thatdecrease the social acceptability of smoking, andthis social pressure may influence some smokers tochange their social comparison group to that ofnonsmokers. On the other hand, being aroundsmokers inhibits smokers' ability to distancethemselves from cigarettes (Gerrard, Gibbons,Lane, & Stock, 2005). Further research is neededon the impact of smoke-free environments and SMIsmokers' behavior.

CONCLUSIONS

Outpatients with SMI indicated a number ofchallenges that they face in embarking on anyprogram of smoking cessation. Smoking is seen ascentral to their daily survival. These smokers lacknot only confidence to quit but also everyday copingskills that can facilitate a life without cigarettes.Social and environmental reinforcement can bothassist and hinder efforts to stop smoking. Smoke-free environmental restrictions can effectivelysupport a person's decision to quit smoking ifpositive social comparisons with nonsmokers occur.Peer modeling and interpersonal connection withnonsmokers are valued and can therefore offer a linkto forming supportive nonsmoking relationships.

ACKNOWLEDGMENT

We thank the International Society of Psychia-tric–Mental Health Nurses for funding this researchproject and the members and staff of Thresholds

Psychiatric Rehabilitation Centers for their supportand participation.

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