Smoking Cessation Support for People with Severe Mental Illness

People with severe mental illness (SMI) have a significantly lower life expectancy than people without SMI due to more prevalent health problems, including cardiovascular diseases, cancers and diabetes. Smoking is one of the most critical lifestyle factors making people with SMI more vulnerable to many of these diseases, along with more drug and alcohol abuse, obesity and adverse effects of antipsychotic medication. Adding to the latter, people who smoke need considerably higher dosages of specific antipsychotic medication to achieve therapeutic concentration levels. Standard programmes for smoking cessation are available, but they do not take the context of mental illness into account, making these programmes less suitable for people with SMI. There is evidence that shows the positive effects of tailored smoking cessation support for people with SMI integrated into mental healthcare settings. This project aimed to develop, implement and evaluate the effectiveness of a smoking cessation intervention (KISMET) for people with SMI in Flexible Assertive Community Treatment (FACT) teams in the Netherlands. Chapter 2 describes the development of the KISMET intervention using a Delphi method, including five experts and three rounds of deliberation. This iterative process resulted in an evidence-based and practice-based intervention adapted to the needs of people with SMI, and trategies for implementation within FACT teams. Three intervention components were identified: group sessions incorporating cognitive behavioural therapy (CBT) and motivational interviewing (MI), a peer support group led by an expert-by-experience and (optional) pharmacological treatment in accordance with treatment guidelines. In Chapter 3, the study protocol of the cluster-randomised controlled trial (RCT) that assessed the effectiveness is presented, including procedures of a process evaluation. A description of the study setting, participants, study outcomes, data collection timeline, and data analysis plan is provided, as well as the KISMET intervention, the training for mental healthcare professionals, and the treatment as usual (TAU) condition. Chapter 4 presents the outcomes of the RCT assessing the effectiveness of the KISMET intervention. Smoking cessation rates were compared between patients participating in the KISMET intervention and those receiving TAU without additional support. In total, 133 participants were included. Follow-ups were conducted at 3, 6 and 12 months. Results showed that in the KISMET group, 32% of participants quit smoking compared to 10% in the control group. At 12 months, more participants in the KISMET group used pharmacological support compared to TAU. There were no significant differences between the two groups regarding mental and physical health outcomes. No physical or psychiatric complications directly related to the intervention occurred. However, the dropout rate was high, particularly in the KISMET group, affecting the reliability of the findings. Chapter 5 presents the process evaluation. Interviews with patients and professionals yielded insights into barriers and facilitators for implementation. Facilitators included effective teamwork, a well-structured intervention manual and the use of carbon monoxide monitoring. Barriers included staff shortages, high workload, high turnover and a lack of organisational embedding. Recruiting and retaining patients was challenging, and tailoring the intervention to individual needs proved difficult in a group setting. Chapter 6 presents the experiences of patients and professionals with the KISMET intervention. Smoking was described as a way to cope with stress, psychiatric symptoms and adverse effects of antipsychotic medication. CBT- and MI-based exercises, personalised relapse prevention plans and the group setting were valued. Increased awareness of smoking behaviour was observed, regardless of smoking cessation outcomes. Finally, Chapter 7 summarises the main findings and discusses implications for practice and future research. The KISMET study demonstrated that people with SMI can achieve smoking cessation and that the KISMET intervention can support this process. Future studies should improve recruitment and retention strategies to strengthen the evidence.