Cutting edge smoking cessation support: SCIMITAR+
Authors: Debbie Robson, Ann McNeill
Journal: The Lancet Psychiatry (2019)

Smoking among people with severe mental illness has remained persistently high during a time when prevalence has been steadily decreasing in the general population.1Szatkowski L McNeill A Diverging trends in smoking behaviours according to mental health status.Nicotine Tob Res. 2015; 3: 356-360Crossref Scopus (84) Google Scholar In The Lancet Psychiatry, Simon Gilbody and colleagues report on smoking cessation intervention for severe mental illness (SCIMITAR+) trial,2Gilbody S Peckham E Bailey D et al.Smoking cessation for people with severe mental illness (SCIMITAR+): a pragmatic randomised controlled trial.Lancet Psychiatry. 2019; (published online April 8.)http://dx.doi.org/10.1016/S2215-0366(19)30047-1Summary Full Text Full Text PDF PubMed Scopus (87) Google Scholar a pragmatic randomised controlled trial assessing a bespoke intervention for smokers with severe mental illness living in the community. Over a 15-month period, 526 eligible smokers were recruited, more than the originally planned 400 participants. An impressive 84% (n=442) of participants were followed up at 12 months; the research team should be congratulated on an aptly designed and well conducted trial. The primary outcome of self-reported 7-day point prevalence abstinence verified by expired-air carbon monoxide (<10 parts per million) at 12 months after randomisation, was not significant (15% [34 of 223] in the intervention group vs 10% [22 of 219] in the control: adjusted odds ratio [OR] 1·6, 95% CI 0·9–2·8; p=0·12). When assessing all participants randomly assigned to treatment, 13% of the intervention group and 8% of the control group were carbon monoxide-verified quitters at 12 months. At 6 months, a significant difference was seen between the two groups for the same outcome measure. Here, two issues of interest exist: first, in the intervention group at 6 months 32 participants were abstinent for a 7-day period and at 12 months 34 participants were abstinent for a 7-day period, compared with 14 participants at 6 months and 22 at 12 months in the control group. The numbers of participants who had stopped for 7 days had therefore increased between 6 months and 12 months in both groups; a finding that needs exploring. We wondered whether this finding might have been due to increased exposure to periods of not smoking or short-term repeated successful quit attempts over time, which might have enhanced participants' confidence in their ability to quit. Second, some differences exist in the outcomes reported here to those set out in the Russell Standard, the gold standard for smoking cessation trials.3West R Hajek P Stead L Stapleton J Outcome criteria in smoking cessation trials: proposal for a common standard.Addiction. 2005; 100: 299-303Crossref PubMed Scopus (815) Google Scholar The most prominent difference is the use of point prevalence rather than the gold standard continuous abstinence, which is only feasible when a target quit date is defined. The baseline characteristics of trial participants indicate high smoking dependence in comparison with smokers in the wider population, and hence the flexible quit date in this trial was appropriate and makes point prevalence abstinence a more comparable measure to use across trial groups. Perhaps we need to redefine the gold standards for treatment outcomes for smoking cessation trials when involving hard-to-treat groups, such as those with severe mental illness. This trial has several implications for clinical practice. The researchers observed no significant differences in mental health outcomes between groups at either timepoint and other previous research indicates that stopping smoking is not associated with a deterioration in mental health;4Taylor G McNeill A Girling A Farley A Lindson-Hawley N Aveyard P Change in mental health after smoking cessation: systematic review and meta-analysis.BMJ. 2014; 348: g1151Crossref PubMed Scopus (608) Google Scholar together these findings should reassure health professionals that this group can quit or try to quit without adverse effects. Contrary to perceptions among some health professionals,5Sheals K Tombor I McNeill A Shahab L A mixed-method systematic review and meta-analysis of mental health professionals' attitudes toward smoking and smoking cessation among people with mental illnesses.Addiction. 2016; 111: 1536-1553Crossref PubMed Scopus (100) Google Scholar the number of participants who engaged with smoking cessation intervention underscores an interest in changing smoking behaviour in this population. Given that the final prescription for medication was decided by the primary care physician, readers might find the data on prescriptions useful. Previous studies have indicated that smokers with severe mental illness are given fewer smoking cessation medications by their primary care physicians per consultation than smokers without mental illness.6Szatkowski L McNeill A The delivery of smoking cessation interventions to primary care patients with mental health problems.Addiction. 2013; 108: 1487-1494Crossref PubMed Scopus (38) Google Scholar Gilbody and colleagues comment on the low prescriptions of varenicline,2Gilbody S Peckham E Bailey D et al.Smoking cessation for people with severe mental illness (SCIMITAR+): a pragmatic randomised controlled trial.Lancet Psychiatry. 2019; (published online April 8.)http://dx.doi.org/10.1016/S2215-0366(19)30047-1Summary Full Text Full Text PDF PubMed Scopus (87) Google Scholar which is disappointing given that it is an effective and safe smoking cessation medication for this population.7Roberts E Eden Evins AE McNeill A Robson D Efficacy and acceptability of pharmacotherapy for smoking cessation in adults with serious mental illness: a systematic review and network meta-analysis.Addiction. 2015; 111: 599-612Crossref Scopus (75) Google Scholar Similarly, data on the proportion of participants in the usual care group who accessed their primary care physician or local stop smoking service would be informative. Although fewer participants quit in the usual care group than in the intervention group, the proportion who quit was similar to that seen among smokers in the wider population who access stop smoking services.8Dobbie F Hiscock R Leonardi-Bee J et al.Evaluating long-term outcomes of NHS stop smoking services (ELONS): a prospective cohort study.Health Technol Assess. 2005; 19: 1-156Crossref Scopus (45) Google Scholar Once an international beacon of evidence-based medicine, UK Government cuts to public health budgets have led to a steady decrease in the commissioning of stop smoking services in England and only one in ten services provide dedicated support to people with a mental health condition.9Action on Smoking and Health and Cancer Research UKA changing landscape: stop smoking services and tobacco control in England. Action on Smoking and Health and Cancer Research, UKMarch 15, 2019Google Scholar Given that smoking is the largest single contributor to health inequalities in the UK, better resourced stop smoking services10Simonavicius E Robson D McEwen A Brose LS Cessation support for smokers with mental health problems: a survey of resources and training needs.J Subst Abuse Treat. 2017; 80: 37-44Summary Full Text Full Text PDF PubMed Scopus (13) Google Scholar and a competent UK National Health Service (NHS) workforce are needed to provide smoking cessation support to all smokers. Over a third of participants (95 [36%] of 265 in the intervention group and 102 [39%] of 261 in the usual care group) used an e-cigarette for the purpose of quitting smoking, another indicator of high motivation to move away from smoking in this population. If e-cigarette users can be supported to stop smoking altogether it could benefit their health, given recent evidence that e-cigarettes can be less harmful than smoking.11Shahab L Goniewicz ML Blount BC et al.Nicotine, carcinogen, and toxin exposure in long-term e-cigarette and nicotine replacement therapy users: a cross-sectional study.Ann Intern Med. 2017; 166: 390-400Crossref PubMed Scopus (325) Google Scholar Health professionals should be offering support to e-cigarette users because combining e-cigarettes with specialist behavioural support or licensed smoking cessation medications, is associated with high success rates.12McNeill A Brose L Calder R Bauld L Robson D Vaping in England: an evidence update February 2019. Public Health England, London2019Google Scholar Finally, publication of the results of the SCIMITAR+ trial is timely, because in January, 2019, the NHS Long-Term Plan committed to funding smoking cessation support, including the option to switch to e-cigarettes, for long-term users of mental health services. Therefore, there should be no further delays to providing urgently needed evidence-based stop-smoking support for this population. AM was the chair of the SCIMTAR+ Trial Steering Committee and DR was a member of the Data Monitoring and Ethics Committee for the final year of the SCIMITAR+ Trial. AM co-chairs the Mental Health and Smoking Partnership. Smoking cessation for people with severe mental illness (SCIMITAR+): a pragmatic randomised controlled trialThis bespoke intervention is a candidate model of smoking cessation for clinicians and policy makers to address high prevalence of smoking. The incidence of quitting at 6 months shows that smoking cessation can be achieved, but the waning of this effect by 12 months means more effort is needed for sustained quitting. Full-Text PDF Open Access