NDARC Technical Report No. 192 (2004)
The prevalence of smoking among people with a psychiatric illness, especially schizophrenia, is much higher than in the general population (Goff et al., 1992). Smoking is associated with adverse mental and physical consequences among people with psychotic disorders. People with a psychotic illness who smoke require an increase in medication due to changes in its metabolism. In turn, this leads to increased side-effects, including dysphoria (Wilhelm, 1998). In terms of adverse physical consequences, smoking related diseases are the greatest contributor to early mortality among people with a psychotic illness (Lawrence, Holma & Jablensky, 2001).
Ziedonis and Williams (2003) have recently summarized the numerous biological, psychological and social factors that may act to increase the risk of nicotine dependence among people with psychotic disorders. Biological factors include: enhancement of dopamine transmission with possible reduction in negative symptoms; possibly an influence on stress, anxiety and depression; and genetic influences on the initiation and maintenance of smoking. Social factors that increase smoking risks include: limited education; poverty; unemployment; peer pressure; and the treatment system. That is, as some patients start daily smoking after the onset of schizophrenia, there may be influences from other patients and the treatment environment on smoking behaviours (Peterson et al., 2003).
Despite the high prevalence of smoking, smoking cessation programs have not typically been part of treatment regimens available to people with psychiatric illness. This is possibly due to the belief that the cognitive, social and affective deficits, including the amotivational state typical of schizophrenia present an insurmountable barrier to change for this group (Addington et al., 1997).
In 2000, the National Health and Medical Research Council of Australia (NHMRC) funded a project entitled “Intervention for smoking among people with a mental illness” (Chief Investigators Baker, Richmond, & Carr), which built on results from a pilot study conducted in 1999. The pilot study received funding from the Australian Rotary Health Research Fund and the Community Health and Anti-Tuberculosis Association.
The above projects aimed to evaluate the effectiveness of a six-session intervention followed by two booster sessions for tobacco dependence on the course of smoking and psychiatric symptomatology among a sample (n=298) of people with a psychotic illness. Participants were recruited from the Sydney and the Newcastle regions of New South Wales, Australia. Almost two-thirds of the study sample were either contemplating quitting or cutting down or were preparing to quit smoking. The fact that people with a psychotic illness are interested in giving up smoking attests to the potential likelihood of attracting sufficient numbers of people if smoking cessation interventions were to be offered by mental health services. This manual describes the psychological intervention for smoking cessation evaluated by this research program.
The development of the intervention was informed by various treatment approaches that have been utilised for smokers. The treatment described in this manual combines motivational enhancement techniques, cognitive behavioural strategies, self-help material and nicotine replacement therapy (NRT).
Organisation of this Manual
The intervention described in this manual was delivered over six weekly sessions, followed by two fortnightly booster sessions, and was conducted on an individual basis.
This manual first describes some of the theoretical and contextual background information relevant to the treatment program, and its evaluation in the randomised controlled trial conducted over 2000-2003. Outcomes for the randomised controlled trial are briefly summarised.
Each subsequent section contains a detailed session-by-session guide to the content of the tobacco reduction intervention evaluated in the randomised controlled trial. Many handouts, homework activities and therapist and client resources are additionally provided.
The intervention was accompanied by use of the SANE Smoke Free Kit (SANE Australia, 1998).
Each session is preceded by a Therapist Summary Sheet that lists all the strategies and information to be covered in the relevant session. Each session description concludes with a Therapist Checklist to assist with clinical note taking, and ensuring all the essential components of the therapy session were covered.
Citation: Baker, A., Kay-Lambkin, F., Bucci, S., Haile, M., Richmond, R., and Carr, V. (2004) Intervention for tobacco dependence among people with a mental illness, Sydney: National Drug and Alcohol Research Centre.