Developing Effective Smoking Cessation Treatment Interventions for Individuals with Severe Mental Illness Who are Homeless or Vulnerably Housed

While tobacco use remains a leading preventable risk factor for mortality and morbidity in Canada (Patra, Rehm, Baliunas & Popova, 2007), the overall smoking prevalence rate of Canadians has decreased substantially from close to 50% of the population in 1965 to 16.1% of the population in 2012 (Canadian Tobacco Use Monitoring Survey (CTUMS) 2012; Reid, Hammond, Rynard & Burkhalter, 2014). However, up to 85% of individuals with a mental illness continue to use tobacco products (Harris, Parle & Gagne, 2007), contributing to an inequitable distribution of negative health outcomes for this population. Individuals with severe mental illness die an estimated twenty-five years earlier than the general population, with sixty per cent of these deaths due to cardiovascular, pulmonary and infectious disease (Parks, Svendsen, Singer, & Foti, 2006). A recent study that examined specific tobacco-attributable deaths in these populations found that tobacco accounted for 53% of deaths in individuals with schizophrenia, 50% of all deaths for those diagnosed with a depressive disorder, and 48% of all deaths for those with a diagnosis of bipolar disorder (Callaghan et al., 2014). This research project is intended to increase our understanding of what constitutes an effective intervention for smoking cessation and smoking reduction in a population of individuals with severe mental illness who are homeless or vulnerably housed, living in a large urban setting. Two areas of inquiry were proposed. The first inquiry examined data collected as part of a needs assessment to determine the overall prevalence rate of smoking and related behaviours for a population of individuals with severe mental illness receiving services from a community mental health agency. We found that the tobacco use prevalence was 72%, and 62% of smokers had high or very high levels of nicotine dependence; however Smoking Cessation Interventions for Individuals with Severe Mental Illness iii almost half of respondents (47%) were interested in quitting or reducing tobacco within the next 6 months. Smokers were found to be over 9 times more likely to have a co-occurring substance use disorder (OR=9.44, 95%CI[6.33,14.08]). The second inquiry was a pilot study conducting a randomized controlled trial design to evaluate smoking cessation and smoking reduction outcomes for two groups of individuals (n=61) with severe mental illness receiving different smoking cessation interventions. Clients randomly assigned to the routine Smoking Cessation group (SC-R) received up to 24 weeks of no-cost Nicotine Replacement Therapy (NRT) and clients assigned to the Smoking Cessation Plus group (SC+) received up to 24 weeks of no-cost Nicotine Replacement Therapy (NRT) plus two initial individual sessions of motivational interviewing followed by weekly psychosocial group interventions for up to 24 weeks. Primary outcomes were levels of tobacco use at the 3-month and 6-month follow-up. The 7day point prevalence abstinence rate measured at 3 months was 21.9% (n=7) for the SC+ group and 13.8% (n=4) for the SC-R group (OR=1.75,95%CI[.46,6.74]). At 6 months, the 7-day point prevalence abstinence rate was 12.5% (n=4) for the SC+ group and 6.9% (n=2) for the SC-R group (OR=1.93, 95%CI[.33,11.41]). Secondary outcomes included change in reported quality of life, physical health and mental health status functioning over the course of the study. We found that there were no statistically significant differences in the smoking quit or smoking reduction rates between the two treatment groups. At the 3-month time point the overall quit rate for both groups combined was 18% (n=11) and at the 6-month time point the quit rate was 10% (n=6). Reduction in the number of daily cigarettes smoked was statistically significant over time (F [1.68, 98.90] = 55.13, p < .001, η p 2 = 0.48) for both Smoking Cessation Interventions for Individuals with Severe Mental Illness iv groups, as was the overall reduction of the FTND score (F [2, 94] = 17.98, p < .001, η p 2 = 0.28). This research demonstrates that collecting vital tobacco prevalence and dependency information is a straightforward and important task for community mental health agencies. Individuals with mental illness have both the interest and ability to quit or reduce their use of tobacco. Practitioners need to be aware of alternative smoking practices that may contribute to understanding tobacco use patterns and dependence in this population. Other factors such as co-morbid substance use disorder and level of community functioning may influence smoking status and, consequently, how treatment is provided. The findings of the pilot trial demonstrate the feasibility of conducting smoking cessation research with the population. Findings also suggest that a larger definitive trial is warranted to examine the effectiveness of the SC+ intervention. This research adds to the limited but growing knowledge base of how to address tobacco use and provide treatment to this vulnerable group, and will contribute to advances in population health by informing effective interventions with the attendant implications for program and policy development. Smoking Cessation Interventions for Individuals with Severe Mental Illness v Acknowledgements This achievement is dedicated to my parents Bill and Rita Pettey. I was privileged to be raised by parents who valued education and who led by example in demonstrating the importance of contributing to your community. It is with deep gratitude that I acknowledge the contribution of the individuals who agreed to participate in this study. Thank-you for bravely working toward, what many of you expressed as, one of the most difficult changes in your lives. I hope that I have properly captured your experiences. It is with equal gratitude that I acknowledge the amazing mentorship, support, and patience that Dr. Tim Aubry has provided to me over these past years as my supervisor. I have no doubt that I would never have been able to undertake this project without his expertise, direction and encouraging approach. I would also like to thank my committee members: Dr. Robert Flynn, Dr. Robert Reid, and Dr. Robert Swenson for the time they have taken to support me in the completion of this project. I would like to thank the board and staff of CMHA Ottawa, my 'second home' for the past 27 years, who have supported me, and this project. In particular, I would like to acknowledge and thank the "Take a Breath" team: Annette Bradfield, Joanne Haddad, Russell Sheridan, Andre Inkel, Derrick Shears, Danny Lang, Craig Defries, Carol Skinner, Jennifer Rae, Michael Whitteker, and Lucy Whitteker. This project happened, and, continues to happen, as a result of your collective energy and commitment. I would like to thank my extended network of family and friends for their ongoing support, in particular, my sisters Carol DeDecker, Marie Hardy, and Sandra Pettey. I also thank my 'sisters in life' for their countless and unique hours of support: Kirsty Jackson, Lisa Smoking Cessation Interventions for Individuals with Severe Mental Illness vi Cormier, Helen Gottfried-UnRuh, Joanne Lowe, Mrs. King, Wendy Muckle, Cousin Dale Teangauba, Margaret Ireland, Juliana Bravo, and my 'little sister' Kerri-Anne Mullen. And of course Murray Krock, Vincent, and Hal. In truth, there are many other people who have helped me along the way on this 'incredible journey'. The Incredible Journey was actually one of my favourite books as a child and provides an apt metaphor for embarking upon a PhD in your late forties. It tells the unlikely tale of two dogs and a cat who, through a series of unlikely circumstances, find themselves in unfamiliar territory, far from home. After much suffering and doubt, they persevere, and only with the assistance from a variety of characters along the way, they find their way back home. But of course, they are changed forever. Smoking Cessation Interventions for Individuals with Severe Mental Illness vii Statement of the Contributions of Thesis Supervisor and Committee Members The proposal for the thesis research was reviewed and accepted by committee member, Drs. Robert Flynn, Robert Reid, and Robert Swenson. Donna L. Pettey conceptualized and conducted the research presented in the thesis under the supervision of Dr. Tim Aubry, who served as the primary thesis advisor. Dr. Aubry also reviewed and provided feedback on the thesis document. In addition, Dr. Robert Flynn was consulted and provided feedback on the two manuscripts presented in the thesis. Both manuscripts involved the work of Dr. Tim Aubry as primary thesis advisor. In addition, Dr. Robert Flynn was consulted and contributed to overall revisions and clarity of the final manuscripts. Smoking Cessation Interventions for Individuals with Severe Mental Illness viii Tables of