Loading

Journal of Substance Abuse and Alcoholism

Characteristics and Predictors of Intention to use Cessation Treatment among Smokers with Schizophrenia: Young Adults Compared to Older Adults

Research Article | Open Access | Volume 5 | Issue 1

  • 1. Department of Psychiatry, Geisel School of Medicine at Dartmouth, USA
  • 2. Hofstra Northwell School of Medicine, USA
  • 3. Thresholds Evaluation and Research Center, USA
  • 4. Department of Psychiatry, University of Massachusetts, USA
  • 5. Rutgcrs University-Robert Wood Johnson Medical School, USA
+ Show More - Show Less
Corresponding Authors
Mary P. Brunette, Geisel School of Medicine at Dartmouth, 105 Pleasant St, Concord NH 03301, USA Tel: 603-271-5747
ABSTRACT

Background: Over half of young adults with schizophrenia smoke. Quitting before age 30 could prevent some of the disparate morbidity and mortality due to smoking-related diseases. However, little research has addressed smoking in this group nor evaluated strategies to help young adults with schizophrenia quit smoking.

Methods: We compared demographic and smoking-related characteristics of young adults and those over 30 years of age among 184 smokers with schizophrenia. With a series of regression models, we assessed whether age, gender, smoking characteristics, social norms, attitudes, and perceived behavioral control predicted intention to quit smoking and to use cessation treatments.

Results: Young adults had smoked for fewer years, had lower nicotine dependence, and had lower breath carbon monoxide levels than those over 30, yet awareness of the harms of smoking and readiness to quit were similar between groups. Attitudes about smoking, attitudes about cessation treatment, social norms for cessation treatment, and perceived behavioral control for cessation treatment significantly predicted intention to use cessation treatment. Age was not a predictor of intention to quit, nor to use cessation treatment.

Conclusions: Young adults with schizophrenia are amenable to smoking cessation intervention. Increasing awareness of the safety, efficacy and access to cessation treatments among smokers with schizophrenia and also among those in their social network may improve use of effective cessation treatment. These strategies may enhance the standard educational approach (increasing awareness of harms).Research is needed to evaluate such intervention strategies in smokers with schizophrenia of all ages.

KEYWORDS

• Smoking
• Tobacco
• Schizophrenia
• Cessation treatment
• Young adult

CITATION

Brunette MF, Feiron JC, Aschbrenner K, Colctti D, Devitt T, et al. (2017) Characteristics and Predictors of Intention to use Cessation Treatment among Smokers with Schizophrenia: Young Adults Compared to Older Adults. J Subst Abuse Alcohol 5(1): 1055.

INTRODUCTION

People with schizophrenia smoke at three times the rate of the general population [1]. Most start to smoke prior to the onset of their mental illness [2], and persist during young adulthood [3]. Population-based surveys indicate that smokers with schizophrenia are less likely to quit than other smokers [1,4]. Further, they smoke more heavily and extract more nicotine per puff than smokers without schizophrenia [5, 6].Given the high rates of smoking and heavier dependence, it is not surprising that this group suffers disparate chronic disease morbidity and early mortality [7].

Because the effect of smoking on health is cumulative over time, quitting at any age is beneficial, but quitting earlier in life (e.g. prior to age 30) could prevent the bulk of smoking-related disease and early mortality [8,9]. However, beyond identifying correlates of smoking (e.g.) [3,10], little research has studied smoking and cessation in young people with schizophrenia, who may have different facilitators and barriers to smoking and quitting.

Although smoking cessation interventions improve outcomes(e.g.) [11,12], and cessation medications are safe and tolerable in this group [13], smokers with schizophrenia and other mental illnesses tend to have misinformation about cessation treatment and prefer to try to quit without treatment, leading to unsuccessful quit attempts [14]. Further information is needed to understand the attitudes, knowledge, and intentions of smokers with schizophrenia regarding quitting and using cessation treatment, with a focus on assessing young adults in order to develop effective strategies to engage these smokers into successful cessation efforts.

The Theory of Planned Behavior has been used to understand health behaviors and to design effective health behavior interventions in the general population and among people with schizophrenia and other mental illnesses [15-17]. This theory posits that beliefs and attitudes about the behavior, social norms for a behavior, and perceived control over the health behavior lead to intentions and behavior change [15]. These constructs have been shown to predict intention to quit smoking in the general population [18]. If these constructs predicted intention to quit smoking and also intention to use cessation treatment in smokers with schizophrenia, this theory could be harnessed to develop effective interventions for this group.

In order to better understand how to intervene with young adult smokers with schizophrenia, we examined baseline data from two studies of similar brief motivational interventions (ClinicalTrials.gov identifiers NCT01779440 and NCT02086162) to assess whether young adult smokers with schizophrenia differ from those over 30, and to examine how age, gender, attitudes and beliefs, social norms and perceived behavioral control of smokers with schizophrenia related to intention to quit smoking and intention to use cessation treatment.

MATERIALS AND METHODS

Study design and procedures

We examined baseline data from two studies of similar, single-session motivational education interventions for smoking cessation among people with schizophrenia and other severe mental illnesses. The interventions were designed for people at any stage of change, and participants did not have to want to quit smoking to participate. Participants for this report comprised the subgroup of 184 participants with schizophrenia spectrum disorders. They provided informed consent and then were assessed by trained interviewers. Participants were paid for research visits. The studies was approved and monitored by the Dartmouth Committee for the Protection of Human Subjects and the institutional review boards of participating sites.

Participants

Participants were recruited between 2012 and 2014 from six outpatient community mental health service organizations in New Hampshire, New Jersey, New York, Massachusetts, and Illinois with flyers and clinician referral. Inclusion criteria for these analyses included: age over 17, diagnosis of schizophrenia spectrum disorders, current mental illness symptom stability, outpatient status, and current daily smoking. Exclusion criteria included not fluent in English, engaged in smoking cessation treatment, current DSM IV-TR diagnoses of drug or alcohol dependence with active use, and pregnant or nursing.

Measures

Demographics and physician-completed DSM IV-TR psychiatric diagnoses were obtained from clinic chart review. With a structured interview and written answer option cue cards, trained interviewers obtainedsmoking history and characteristics,family history of smoking, social context of smoking, and smoking attitudes.Current substance use was assessed with a quantity-frequency measure to augment substance use disorder diagnosis (for exclusion criteria) [19,20]. Breath expired carbon monoxide [21], was assessed using a Smokerlyzer Breath Carbon Monoxide Monitor (Bedfont Scientific). Level of dependence was assessed with The Fagerström Test for Nicotine Dependence [22], a six-item measure that has been shown to have reasonable internal consistency and test-retest reliability among smokers with schizophrenia [23]. Attitudes about smoking were assessed with the Attitudes Towards Smoking (ATS) Scale, an 18-item scale with three subscales (adverse effects, benefits, pleasure) [24].Test-retest correlations are high (above 0.81), and the total score (calculated as the benefits plus pleasuresubscales minus the adverse effects subscale)has predicted smoking cessation in general population smokers. The Wide Range Achievement Test (WRAT) subtest for reading comprehension (a well validated and widely used assessment to estimate premorbid cognitive function) assessed participants for reading comprehension [25].

A 48 item Theory of Planned Behavior questionnaire was used to assess participants for beliefs about: cessation and using cessation treatment, social norms regarding cessation treatment,and perceived behavioral control over cessation treatment;and well as intentions to quit and to use cessation treatment. We developed this questionnaire using Ajzen’s method [26], and refined it in previous studies [27,28]. Examples of items include: “Taking nicotine replacement therapy will help me cut down and quit smoking” and “My friends and boyfriend/girlfriend would approve of me using nicotine replacement therapy to quit smoking.” Answer options for these questions utilized a 7-point Likert scale:1=completely disagree; 4 = neutral; 7=completely agree. Research staffalso assessed participants for smokingrelated stigma and discrimination withthe Stigma of Smoking Questionnaire, which includesquestions about perceptions of devaluation, perceived differential treatment, social withdrawal, and secrecy related to smoking using a 4 point Likert scale,such as “ Most people think less of a person who smokes” 1=Strongly Disagree, 2= Disagree, 3= Agree, 4= Strongly Agree [29].

Intention to quit smoking was measured with the fouritem Stages of Change questionnaire [30], including 1) Precontemplation - not thinking of quitting; 2) Contemplation: thinking of quitting but not in the next month, 3) Preparation: intending to quit in the next month, and 4) Action: Trying to quit now. Answers were collasped as follows: intention to quit is present if answers were 3 or 4; intention to quit was absent if answers were 1 or 2.

Intention to use nicotine replacement therapy to quit and intention to use cessation medication to quit were assessed with continuous variables from the Theory of Planned Behavior Questionnaire described above, including “I have decided to take nicotine replacement therapy to help me quit smoking” and “I have decided to take a medication to help me quit smoking.”

Statistical analysis

Descriptive statistics were used to characterize the study sample. We tested differences between age groups (young adults and those over 30 years of age) with chi-square tests and t-tests. We then constructed three series of regression models, adjusted for age and gender, to understand the relationships between smoker characteristics and our three dependent variables: intention to quit smoking (dichotomous; see above), intention to use nicotine replacement therapy (continuous; see above), and intention to use cessation medications (varenicline or bupropion; continuous; see above). Variables representing smoker characteristics were added in steps: 1) demographics, 2) severity of smoking and attitudes about smoking, 3) social norms for the target dependent variables, 4) beliefs about the dependent variable, and 5) perceived behavioral control regarding the dependent variable. We used logistic regression in the model with intention to quit within the next month (present or absent) and multivariate ordinary least squares regression in the models with intention to use nicotine replacement therapy for cessation and to use cessation medication (bupropion or varenicline).

RESULTS AND DISCUSSION

Study participants

Demographics and smoking characteristics are shown in Table (1). As expected, the young adults younger, less likely to be married, and reported fewer lifetime psychiatric hospitalizations. They were more likely to be male. Regression models therefore included gender as a covariate to adjust for the difference in gender between the age groups.

Table 1: Socio demographic and smoking characteristics of 184 participants with schizophrenia.

  Total Group Young adult Adult
  N=184 (100%) N=43 (23.4%) N=141 (76.7%)
Demographics      
Male, N (%)** 132 (71.4) 39 (90.7) 93 (66.0)
Age, mean (SD)*** 42.96 (12.7) 25.74 (3.6) 48.21 (9.4)
Never married, N (%)** 148 (80.4) 42 (97.7) 106 (75.2)
Years education, mean (SD) 11.88 (2.3) 12.09 (1.9) 11.81 (2.4)
WRAT reading score, mean (SD) 50.06 (10.8) 50.63 (13.3) 49.94 (10.2)
Race and ethnicity      
White, N (%) 55 (29.9) 12 (27.9) 43 (30.5)
Black, N (%) 97 (52.7) 24 (55.8) 73 (51.8)
Other race, N (%) 32 (17.4) 7 (16.3) 25 (17.7)
Hispanic, N (%) 22 (12.0) 3 (7.0) 19 (13.5)
Lifetime psychiatric hospitalizations, mean (SD)*** 10.3 (12.7) 6.1 (5.2) 11.6 (14.0)
Smoking Characteristics      
Cigarettes/day, mean (SD) 14.01 (10.3.) 12.50 (12.8) 14.47 (9.4)
Light smokers (<15 cigarettes/day), N (%)# 117 (63.6) 31 (72.1) 86 (61.0)
Moderate smokers (15-25 cigarettes/day), N (%) 44 (23.9) 10 (23.3) 34 (24.1)
Heavy smokers (>25 cigarettes/day, N (%) 23 (12.9) 2 (4.7) 21 (14.9)
Fagerstrom dependence score, mean (SD) ** 5.0 (2.0) 4.2 (2.1) 5.24 (2.0)
Breath Carbon Monoxide, mean (SD) *** 25.9 (19.5) 15.9(10.5) 28.7 (20.5)
Age first started smoking regularly, mean (SD) * 19.0 (6.5) 17.7 (2.7) 19.4 (7.2)
Quit attempt in past 3 months, N (%) 54 (29.4) 16 (37.2) 38 (27.0)
Attitudes and knowledge about smoking      
ATS Adverse effects of smokinga , mean (SD) 38.59 (8.3) 39.21 (7.7) 38.40 (8.5)
ATS Benefits of smokinga , mean (SD) 14.32 (3.5) 14.21 (3.7) 14.35 (3.4)
ATS Pleasure of smokinga , mean (SD) 14.05 (3.7) 14.72 (3.8) 13.85 (3.7)
ATS Summary score, mean (SD) -10.21 (10.8) -10.28 (9.5) -10.20 (11.2)
Knowledge score smoking and cessation treatmentb , mean (SD) 64(16.3) 63 (17.3) 65 (16.0)
Tobacco product use1      
Prerolled cigarettes 150 (82.9) 36 (83.7) 114 (82.6)
Loose tobacco for rolling cigarettes 10 (5.5) 1 (2.3) 9 (6.5)
Both prerolled and loose tobacco for cigarettes 21 (11.6) 6 (14.0) 15 (10.9)
Mini Cigars * 73 (39.7) 11 (25.6) 62 (44.0)
Cigars 31 (16.9) 11 (25.6) 20 (14.2)
Hookah * 4 (2.2) 3 (7.0) 1 (0.7)
Chew * 2 (1.1) 2 (4.7) 0
Electronic * 29 (15.8) 11 (25.6) 18 (12.8)
Menthol 145 (80.6) 34 (81.0) 111 (80.4)
Stage of change for cessation      
Ready to quit this month, N (%) 53 (28.8) 10 (23.3) 43 (30.5)
Thinking of quitting but not in next month, N (%) 57 (31.0) 16 (37.2) 41 (29.1)
Not thinking of quitting, N (%) 74 (40.2) 17 (39.5) 57 (40.4)
       
Intention to use cessation treatment, Mean (SD)c      
Intention to use nicotine replacement therapy 3.8 (2.1) 3.6 (1.8) 3.8 (2.2)
Intention to use cessation medication 3.4(2.1) 3.0 (2.0) 3.5 (2.1)
WRAT - Wide Range Achievement TestATS - Attitudes Towards Smoking Scale
*p<.05; **p<.01; ***p<.001; Young adults significantly different from older adults
 
# White were more likely than Blacks and Other Race to be in the heavy smoker group  
a Adverse effects of smoking possible range = 10-50; Benefits and Pleasure of smoking possible range 4-20  
b Knowledge scores ranged from 16.6 - 91.6% correct, possible range = 0-100      
c 1=completely disagree; 7= completely agree
1 1 subject used cigars only, 2 subjects used mini cigars only
 
     

The group smoked an average of 14 cigarettes per day and had a moderate level of nicotine dependence. Less than 15% were classified as heavy smokers (25 cigarettes per day or more). Whites were more likely to be heavy smokers than Blacks and those who endorsed Other Race (27.3% vs.6.2% vs. 6.3 %; Chi2 =15.7; p<.001.

The young adults with schizophrenia had smoked for a shorter period of time than the older adult group (7 vs. 29 years on average) and had significantly lower nicotine dependence scores, with correspondingly lower breath carbon monoxide levels. Young adults were significantly more likely to report past month use of hookah, chew and electronic cigarettes, and they were less likely to report past month use of little cigars.

Both young adults and the smokers over 30 reported high levels of awareness of adverse effects of smoking and also high endorsement of pleasure and benefits from smoking; the composite attitudes scores were negative, indicating overall greater endorsement of negative compared to positive attitudes towards smoking. About a third had tried to quit in the past 3 months. Intention to quit was similar between age groups: about a third of the group was in the preparation or action stage, wanting to quit within a month. Although intentions to use nicotine replacement therapy and cessation medication were similar in young adults and those over 30, young adults indicated a higher preference for quitting without medications, or “cold turkey” (t=-2.06; p=.04).

The social context variables are shown in Table (2).

Table 2: Social context, perceptions of approval and stigma among smokers with schizophrenia.

  Total Group Young adult Adult
Social context of smoking N=184 N=43 N=141
Smoking allowed inside home, N (%)*** 89 (48.6) 9 (20.9) 80 (57.1)
Family (of origin) member smokes, N (%) 161 (87.5) 37 (86.1) 124 (87.9)
Smoking companions past week, Mean (SD) 2.98 (6.5) 2.97 (4.5) 2.99 (7.0)
Nonsmoking companions past week, Mean (SD)* 2.25 (3.2) 3.20 (3.6) 1.98 (3.0)
Perceptions of social approval for cessation strategies    
Friends/boy- or girlfriend approval for quitting cold turkey*** 4.98 (1.8) 5.86 (1.4) 4.71 (1.9)
Friend approval NRT 5.17 (1.8) 5.55 (1.6) 5.06 (1.9)
Friend approval cessation medication 4.86 (1.7) 5.07 (1.8) 4.80 (1.7)
Smoking-related stigma and discrimination concerns    
Social Withdrawal Score (range 0-9), Mean (SD) 5.12 (1.9) 4.51 (2.0) 5.36 (1.8)
Devaluation Score (range 0-6), Mean (SD) 3.1 (1.4) 2.6 (1.4) 3.21 (1.4)
Secrecy, N (%) 73 (39.7) 22 (51.2) 51 (36.2)
Perceived Differential Treatment, N (%) 50 (27.2) 11 (25.6) 39 (27.7)
*p≤.05; **p≤.01; ***p≤.001;      

Young adults spent time with a greater number of nonsmokers than did the adults over 30(t=-2.17; p=.03) and were more likely to report that smoking was not allowed inside their home(X2 =17.27, p<.0001). Regarding perceptions of social approval for methods of cessation, young adults reported greater perceptions that friends would approve of their quitting cold turkey (t=-4.22; p=.0001), but perceptions that friends would approve of their using nicotine replacement therapy and cessation medications were positive and not different between the age groups.

Smokers who were more ready to quit smoking endorsed more positive attitudes about smoking cessation medication (r=.26, p<.001) and nicotine replacement therapy (r=.28, p=.0001). Additionally, social norms regarding use of cessation medication and nicotine replacement therapy were stronger for people who were more ready to quit. Those who were more ready to quit smoking reported greater perceptions of friend approval for using cessation medications (F=8.17; p=.0004) and nicotine replacement therapy (F=6.85; p=.001).

Predictors of intention to quit smoking

Bivariate logistic regression models found that attitudes about smoking (ATS composite score) were associated with intention to quit (OR= .92 (89-96), p<.0001); but age, gender, smoking characteristics, social context variables and perceived behavioral control were not associated with intention to quit smoking.

Predictors of intention to use nicotine replacement therapy

As shown in Table (3), in Step 1, age and genders were not significant predictors of intention to use nicotine replacement therapy.

Table 3: Ordinary least squares regression predicting intention to use Nicotine Replacement Therapy.

  Model 1 Model 2 Model 3 Model 4 Model 5
Predictor Variables Β SE Β β Β SE Β β Β SE Β β Β SE Β β Β SE Β β
(Step 1) Demographics                              
Age 0.01 0.01 0.08 0.01 0.01 0.08 0.01 0.01 0.08 0.01 0.01 0.09 0.01 0.01 0.06
Gender 0.49 0.35 0.1 0.62 0.35 0.13 0.43 0.35 0.09 0.08 0.32 0.02 0.09 0.31 0.02
(Step 2) Smoking characteristics                              
Fagerstrom       -0.08 0.08 -0.07 -0.06 0.08 -0.06 -0.04 0.07 -0.03 -0.04 0.07 -0.03
Attitudes Toward Smoking           -0.04*** 0.01 -0.25 -0.03* 0.01 -0.16 -0.02 0.01 -0.12 -0.02 0.01 0.04
(Step 3) Social Norms                              
Friends would approve             0.29*** 0.09 0.25 0.18* 0.08 0.15 0.13 0.08 0.11
Know someone             0.1 0.06 0.13 0.04 0.05 0.05 0.04 0.05 0.05
(Step 4) Beliefs                              
NRT Importance                   0.31*** 0.10 0.22 0.24* 0.10 0.17
Positive attitudes                   0.14*** 0.03 0.29 0.12*** 0.03 0.25
(Step 5) Perceived Behavior Control
If I wanted, I could…                         0.28** 0.10 0.21
R2 0.02     0.09     0.17                          0.34                       0.38
Adjusted R2 0.01     0.07     0.14                           0.31                       0.34
Note: SE = standard error; * = p < .05, ** = p < .01, ***=p<.001

In the successive steps (shown in Table (3), smoking characteristics, attitudes about smoking, social norms, beliefs about nicotine replacement therapy, and perceived behavioral control over use of nicotine replacement therapy were significant predictors of intention to use nicotine replacement therapy. The final model, which included all variables (shown in last column in Table (3) accounted for 38% of the explained, unadjusted variance, and 34% of the adjusted explained variance, in intention to use nicotine replacement therapy, and this model was statistically significant (F=11.06, p<.0001).

Predictors of intention to use smoking cessation medications

Table (4) presents the results of the regression analyses examining predictors of using smoking cessation medications (bupropion and varenicline).

Table 4: Ordinary least squares regression predicting intention to use cessation medication.

  Model 1 Model 2 Model 3 Model 4 Model 5
  B SE B β B SE B β B SE B β B SE B β B SE B β
Predictor Variables
(Step 1) Background Characteristics
Age 0.02 0.01 0.11 0.02 0.01 0.1 0.02 0.01 0.1 0.01 0.01 0.06 0.01 0.01 0.06
Gender 0.12 0.35 0.03 0.19 0.35 0.04 0.04 0.34 0.01 0.13 0.33 0.03 0.1 0.32 0.02
(Step 2) Smoking characteristics
Fagerstrom       0.02 0.08 0.02 0.04 0.08 0.04 0.06 0.07 0.06 0.07 0.07 0.07
Attitude Towards Smoking       -0.04 0.01 -0.23 -0.03 0.01 -0.03 -0.03 0.01 -0.14 -0.02 0.01 -0.11
(Step 3) Social Names
Friends Approve             0.32*** 0.09 0.28 0.13 0.09 0.11 0.08 0.09 0.07
Know someone             0.01 0.06 0.02 0.02 0.06 0.02 0.03 0.05 0.04
(Step 4) Beliefs                              
Medication                   0.04 0.09 0.03 -0.01 0.09 -0.01
importance                   0.13*** 0.03 0.33 0.12*** 0.03 0.29
Positive attitude                              
(step 5) Perceived Behavioral control
if I wanted I could                         0.24** 0.08 0.22
R2 0.01     0.07     0.04       0.22     0.26  
Adjust R2 0.002     0.04     0.11       0.18     0.22  
Note: SE=standard error, * =p< 05, **= p< 01, ***=p<001

In the successive steps, smoking characteristics, attitudes about smoking, social norms, beliefs about cessation medication, and perceived behavioral control significantly predicted intention to use nicotine replacement therapy. The final model, which included all variables (shown in last column in Table 4) accounted for 26% of the explained, unadjusted variance, and 22% of the explained, adjusted variance, in intention to use smoking cessation medication and was significant (F=6.46, p<.0001).

DISCUSSION

This large group of smokers with schizophrenia, we found key similarities and differences between young adults and adults over 30. The young adults had, as expected, smoked for a shorter period of time than the older adult group (7 vs. 29 years on average), and, similar to general population young adults, they reported lower levels of nicotine dependence [31], and were more likely to use additional tobacco products, such as hookah and electronic cigarettes [32]. Also, as expected given trends in the U.S. [33,34], the young adult group reported higher levels of contact with nonsmokers and home indoor smoking restrictions. Despite their shorter smoking careers and lower level of dependence, the young adults with schizophrenia endorsed a similarly high level of awareness of the negative effects from smoking compared to the level of interest in adults over 30. Additionally, age did not significantly predict intention to quit or to use cessation treatment –indicating that young adults are similar to adults over 30 regarding their interests in cessation and cessation treatment.

We found that measures of attitudes about smoking, social norms for using cessation treatment, attitudes about cessation treatment and perceived control over using cessation treatment all predicted intention to use cessation treatment. These data provide some support for use of the Theory of Planned Behavior in the development of interventions and insight into strategies for engaging smokers with schizophrenia into cessation treatment. Public health efforts and the medical community have focused on increasing smokers’ awareness of the harms of smoking. Our data indicate that smokers with schizophrenia are indeed aware of these harms, and this awareness was related to intention to quit smoking. However, awareness of smoking harms is not enough. These data indicate that, consistent with the Theory of Planned Behavior(15), perceptions about cessation treatments, the social norms for cessation treatments, and perceived behavioral control for using treatments contributed to intention to use them. Thus efforts to engage smokers with schizophrenia into effective cessation interventions should address these areas. This is particularly important because medications such as bupropion and varenicline combined with counseling may be the most robust cessation treatments for smokers with schizophrenia [13,35-37].To enhance engagement, smokers’ knowledge and attitudes about cessation treatments can be improved with education, motivational strategies, and decision support [38-41].

Additionally, the knowledge and attitudes of the family and friends of smokers with schizophrenia can also be improved to shift social norms related to cessation treatments. Recent research has begun to document the social influences on use of smoking cessation treatment [42].Thus improving the knowledge of these smokers’ social networks regarding the safety and efficacy of cessation treatment could increase their willingness to support and encourage smokers with schizophrenia. Since the young adults spent more time with nonsmokers, nonsmoking peers could potentially be harnessed as facilitators of smoking cessation.

Further, access to cessation treatment remains critical and should be well advertised, thus increasing perceived behavioral control over using cessation treatments. While most Medicaid programs provide reimbursement for some form of biological cessation treatment, access may be limited by a variety of insurance company restrictions such as prior authorization and copays [43], or may be financially unobtainable for most smokers with schizophrenia due to low income [44].

A previous summary of world samples reported between 1991 and 2004 indicated that 31% to 46% of outpatient smokers with schizophrenia were heavy smokers [45], whereas only 13% of our sample consisted of heavy smokers. The proportion of heavy smokers was lower in our study sample in part due to the relatively large proportion of African Americans, who tend to be light smokers [46]. However, only 27% of White people in this group smoked heavily, a proportion that is lower than in previously reported clinical samples [45].

The lower levels of smoking found in this study suggests that the level of nicotine dependence in people with schizophrenia may be declining in a pattern similar to the general U.S. population [31]. Alternatively, use of other noncombustible products supplementing cigarettes, such as electronic cigarettes, may have contributed to lower use of combustible tobacco, lower breath CO readings, and possibly erroneous lower ratings of nicotine dependence. Research on the impact of electronic cigarettes on smoking in schizophrenia is in early stages [47- 49]. Nevertheless, a lower level of combustible tobacco smoking is promising for health impacts, but “light smoking” is still associated with substantially elevated risks for cardiovascular diseases, cancers and other diseases compared to no smoking [9,50]. People with schizophrenia are still much more likely to start smoking cigarettes and less likely to quit smoking then people without schizophrenia [1], thus they remain an important disparity population in need of intervention.

Several study limitations warrant discussion. These cross-sectional data describe smokers with schizophrenia who were willing to enroll in a motivational education intervention study. While we enrolled a diverse group from clinics in five states, these smokers may not be representative of all smokers with schizophrenia. Additionally, smoking cessation is a key outcome that was not assessed in this cross-sectional study. Future analyses will evaluate whether baseline characteristics relate to quit attempts and cessation over time.

CONCLUSION

This study shows that young adult smokers with schizophrenia differ from adults over age 30 in patterns similar to general population smokers, yet young adults with schizophrenia had substantial levels of awareness of the negative effects of smoking and similar levels of desire to quit. The relationships we found between social norms, beliefs, and perceived behavioral control for use of nicotine replacement therapy and cessation medications indicate that ongoing efforts to engage smokers with schizophrenia of all ages into effective treatment need to address these concepts. Further research is needed to evaluate strategies to help smokers with schizophrenia engage in cessation activities and to utilize effective cessation treatment.

ACKNOWLEDGMENTS

The authors gratefully acknowledge the support of the study participants, the service providers at the participating Agency’s programs, and the Research Departments at these agencies for their contributions to this study

REFERENCES

1. McClave AK, McKnight-Eily LR, Davis SP, Dube SR. Smoking characteristics of adults with selected lifetime mental illnesses: results from the 2007 National Health Interview Survey. Am J Public Health. 2010; 100: 2464-2472.

2. Correll CU, Robinson DG, Schooler NR, Brunette MF, Mueser KT, Rosenheck RA, et al. Cardiometabolic Risk in Patients With First-Episode Schizophrenia Spectrum Disorders: Baseline Results From the RAISE-ETP Study. JAMA Psychiatry. 2014; 71: 1350-1363.

3. Myles N, Newall HD, Curtis J, Nielssen O, Shiers D, Large M. Tobacco use before, at, and after first-episode psychosis: a systematic metaanalysis. J Clin Psychiatry. 2012; 73: 468-475.

4. Smith PH, Mazure CM, McKee SA. Smoking and mental illness in the U.S. population. Tob Control. 2014; 23: e147-153.

5. Williams JM, Ziedonis DM, Abanyie F, Steinberg ML, Foulds J, Benowitz NL. Increased nicotine and cotinine levels in smokers with schizophrenia and schizoaffective disorder is not a metabolic effect. Schizophr Res. 2005; 79: 323-335.

6. Tidey JW, Rohsenow DJ, Kaplan GB, Swift RM. Cigarette smoking topography in smokers with schizophrenia and matched non-psychiatric controls. Drug Alcohol Depend. 2005; 80: 259-265.

7. Callaghan RC, Veldhuizen S, Jeysingh T, Orlan C, Graham C, Kakouris G, et al. Patterns of tobacco-related mortality among individuals diagnosed with schizophrenia, bipolar disorder, or depression. J Psychiatr Res. 2014; 48: 102-110.

8. Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ. 2004; 328:519.

9. Taghizadeh N, Vonk JM, Boezen HM. Lifetime Smoking History and Cause-Specific Mortality in a Cohort Study with 43 Years of Follow-Up. PLoS One. 2016; 11: e0153310.

10. Myles N, Newall H, Compton MT, Curtis J, Nielssen O, Large M. The age at onset of psychosis and tobacco use: a systematic meta-analysis. Soc Psychiatry Psychiatr Epidemiol. 2012; 47: 1243-1250.

11. Tidey JW, Miller ME. Smoking cessation and reduction in people with chronic mental illness. BMJ. 2015; 351: h4065.

12. Evins AE, Cather C. Effective Cessation Strategies for Smokers with Schizophrenia. Int Rev Neurobiol. 2015; 124: 133-147.

13. Anthenelli RM, Benowitz NL, West R, St Aubin L, McRae T, Lawrence D, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a do. Lancet. 2016; 387: 2507-2520.

14. Ferron JC, Brunette MF, He X, Xie H, McHugo GJ, Drake RE. Course of smoking and quit attempts among clients with co-occurring severe mental illness and substance use disorders. Psychiatr Serv. 2011; 62: 353-359.

15. Ajzen I. The theory of planned behaviour: reactions and reflections. Psychol Health. 2011; 26: 1113-1127.

16. Webb MS, de Ybarra DR, Baker EA, Reis IM, Carey MP. Cognitivebehavioral therapy to promote smoking cessation among African American smokers: a randomized clinical trial. J Consult Clin Psychol. 2010; 78: 24-33.

17. Kopelowicz A, Wallace CJ, Liberman RP, Aguirre F, Zarate R, Mintz J. The use of the Theory of Planned Behavior to predict medication adherence in schizophrenia. Clin Sch Rel Psy. 2007; 227-242.

18. Borland R, Owen N, Hill D, Schofield P. Predicting attempts and sustained cessation of smoking after the introduction of workplace smoking bans. Health Psychol. 1991; 10: 336-342.

19. Sobell LC, Sobell MB. Timeline Follow-Back: A technique for assessing self-reported alcohol consumption. In: Litten RZ, Allen J. Measuring Alcohol Consumption: Psychosocial and Biological Methods. Totowa, NJ: Humana Press. 1992: 41-72.

20. Sobell LC, Sobell MB. Alcohol Timeline Followback (TLFB) Users Manual. Toronto, Canada: Addiction Research Foundation. 1996.

21. Jarvis MJ, Russell MA, Saloojee Y. Expired air carbon monoxide: a simple breath test of tobacco smoke intake. Br Med J. 1980; 281: 484- 485.

22. Fagerström KO. Measuring degree of physical dependence to tobacco smoking with reference to individualization of treatment. Addict Behav. 1978; 3: 235-241.

23. Weinberger AH, Reutenauer EL, Allen TM, Termine A, Vessicchio JC, Sacco KA, et al. Reliability of the Fagerstrom Test for Nicotine Dependence, Minnesota Nicotine Withdrawal Scale, and Tiffany Questionnaire for Smoking Urges in smokers with and without schizophrenia. Drug Alcol Depend. 2007; 86: 278-282.

24. Etter JF, Humair JP, Bergman MM, Perneger TV. Development and validation of the Attitudes towards Smoking Scale (ATS-18). Addiction. 2000; 95: 613-625.

25. Wilkinson G, Robertson G, Lutz F. Wide Range Achievement Test 4 professional manual. 2006.

26. Ajzen I. Constructing a TpB Questionnaire: Conceptual and methodological considerations. 2006.

27. Ferron JC, Brunette MF, McGurk S, H. X, Frounfelker R, Cook JA. Do symptoms and cognitive problems affect the use and efficacy of a web-based decision supporty system for smokers with serious mental illness? J Dual Diagn. 2012; 8: 315-325.

28. Ferron JC, Devitt T, McHugo GJ, A Jonikas J, Cook JA, Brunette MF. Abstinence and Use of Community-Based Cessation Treatment after a Motivational Intervention Among smokers with Severe Mental Illness. Community Ment Health J. 2016; 52: 446-456.

29. Stuber J, Galea S, Link B, xa G. Stigma and Smoking: The Consequences of Our Good Intentions. Social Service Review. 2009; 83: 585-609.

30. DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF, Velasquez MM, Rossi JS. The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psychol. 1991; 59: 295-304.

31. Pierce JP, White MM, Messer K. Changing age-specific patterns of cigarette consumption in the United States, 1992-2002: Association with smoke-free homes and state-level tobacco control activity. Nicotine & Tobacco Research. 2009; 11: 171-177.

32. Lee YO, Hebert CJ, Nonnemaker JM, Kim AE. Multiple tobacco product use among adults in the United States: cigarettes, cigars, electronic cigarettes, hookah, smokeless tobacco, and snus. Prev Med. 2014; 62: 14-19.

33. Secades-Villa R, Olfson M, Okuda M, Velasquez N, Pérez-Fuentes G, Liu SM, et al. Trends in the prevalence of tobacco use in the United States, 1991-1992 to 2004-2005. Psychiatr Serv. 2013; 64: 458-465.

34. King BA, Patel R, Babb SD, Hartman AM, Freeman A. National and state prevalence of smoke-free rules in homes with and without children and smokers: Two decades of progress. Prev Med. 2016; 82: 51-58.

35. Williams J, Anthenelli R, Morris C, Treadow J, Thompson J, Yunis C, et al. A Randomized, Double-Blind, Placebo-Controlled Study Evaluating the Safety and Efficacy of Varenicline for Smoking Cessation in patients with Schizophrenia or schizoaffective disorder. J Clini Psychiatr. 2012; 73: 654-660.

36. Evins AE, Cather C, Pratt SA, Pachas GN, Hoeppner SS, Goff DC, et al. Maintenance treatment with varenicline for smoking cessation in patients with schizophrenia and bipolar disorder: a randomized clinical trial. JAMA. 2014; 311: 145-154.

37. George TP, Vessicchio JC, Sacco KA, Weinberger AH, Dudas MM, Allen TM, et al. A placebo-controlled trial of bupropion combined with nicotine patch for smoking cessation in schizophrenia. Biol Psychiatry. 2008; 63: 1092-1096.

38. Steinberg ML, Williams JM, Stahl NF, Budsock PD, Cooperman NA. An Adaptation of Motivational Interviewing Increases Quit Attempts in Smokers with Serious Mental Illness. Nicotine Tob Res. 2016; 18: 243- 250.

39. Steinberg M, Ziedonis DM, Krejci JA, Brandon TH. Motivational interviewing with personalized feedback: a brief intervention for motivating smokers with schizophrenia to seek treatment for tobacc. J Consult Clin Psychol. 2004; 72: 723-728.

40. Cather C, Freidman-Yakoobian M, Gottlieb JD, Park E, Goff DC, Henderson DC, et al. A randomized controlled trial of motivational interviewing compared to psychoeducation for smoking precontemplators with severe mental illness. Society for Research on Nicotine and Tobacco. 2010.

41. Williams J, Dwyer M, Verna M, Zimmermann MH, Gandhi KK, Galazyn M, et al. Evaluation of the CHOICES program of peer-to-peer tobacco education and advocacy. Community Ment Health J. 2011; 47: 243- 251.

42. Aschbrenner K, Ferron J2, Mueser K3, Bartels S4, Brunette M2. Social predictors of cessation treatment use among smokers with serious mental illness. Addict Behav. 2015; 41: 169-174.

43. Singleterry J, Jump Z, DiGiulio A, Babb S, Sneegas K, MacNeil A, et al. State Medicaid Coverage for Tobacco Cessation Treatments and Barriers to Coverage - United States, 2014-2015. MMWR Morb Mortal Wkly Rep. 2015; 64: 1194-1199.

44. Steinberg ML, Williams JM, Ziedonis DM. Financial implications of cigarette smoking among individuals with schizophrenia. Tob Control. 2004; 13: 206.

45. de Leon J, Diaz FJ. A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors. Schizophrenia Research. 2005; 76: 135-157.

46. Hickman NJ 3rd, Delucchi KL, Prochaska JJ. A population-based examination of cigarette smoking and mental illness in Black Americans. Nicotine Tob Res. 2010; 12: 1125-1132.

47. Pratt SI, Sargent J, Daniels L, Santos MM, Brunette M. Appeal of electronic cigarettes in smokers with serious mental illness. Addict Behav. 2016; 59: 30-34.

48. Caponnetto P, Auditore R, Russo C, Cappello GC, Polosa R. Impact of an electronic cigarette on smoking reduction and cessation in schizophrenic smokers: a prospective 12-month pilot study. Int J Environ Res Public Health. 2013; 10: 446-461.

49. Prochaska JJ, Grana RA. E-cigarette use among smokers with serious mental illness. PLoS One. 2014; 9: 113013.

50. Schane RE, Ling PM, Glantz SA. Health effects of light and intermittent smoking: a review. Circulation. 2010; 121: 1518-1522.

Brunette MF, Feiron JC, Aschbrenner K, Colctti D, Devitt T, et al. (2017) Characteristics and Predictors of Intention to use Cessation Treatment among Smokers with Schizophrenia: Young Adults Compared to Older Adults. J Subst Abuse Alcohol 5(1): 1055.

Received : 04 Feb 2017
Accepted : 21 Mar 2017
Published : 23 Mar 2017
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Clinical Oncology and Research
ISSN : 2373-938X
Launched : 2013
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X