Systematic Review of Psychosocial Smoking Cessation Interventions for People with Serious Mental Illness

Background and Purpose

Tobacco smoking is a major driver of premature mortality and chronic disease in people with serious mental illness (SMI; e.g., schizophrenia, bipolar disorder). This systematic literature review described randomized control trials of psychosocial smoking cessation interventions for people with SMI, rated their methodological rigor, evaluated the inclusion of racial/ethnic minorities and sexual/gender minorities, and examined smoking cessation outcomes.

Methods

We used the Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines to conduct our systematic literature review. Electronic bibliographic databases were used to locate articles: 1) published between 2009 and 2020, 2) tested the impact of a psychosocial smoking cessation intervention among people with SMI, and 3) reported measures of smoking abstinence or reduction as a primary outcome. Two independent reviewers used a standardized instrument to rate studies' methodological rigor and to abstract study characteristics.

Results

Eighteen randomized trials of psychosocial smoking cessation interventions for people with SMI were included. Methodological Quality Rating Scale (MQRS) scores ranged from 9 to 16 with a mean score of 11.8. Ten were categorized as high methodological rigor given their study characteristics (e.g., longer follow-up) and eight as lower methodological rigor based on their characteristics (e.g., not intent-to-treat). Nine studies disaggregated and reported the race/ethnicity characteristics of their sample, and only three studies reported the percentage of participants who identified as sexual or gender minorities. Racial/ethnic and sexual/gender minorities were underrepresented in these studies. Only one study reported making cultural adaptations to their intervention. Interventions ranged from 22-day contingency management interventions to multifaceted healthy lifestyle interventions lasting nine months. Interventions were delivered in individual and group sessions via in-person, telephone, or web-based. An array of interventionists delivered the sessions, including mental health clinicians, nurses, telephone counselors, research staff, and peer specialists. Most studies also provided smoking cessation medications (e.g., NRT, bupropion), although provision was not always uniform across treatment conditions. The most common smoking cessation outcomes measured in the included studies were abstinence (88.9%), reductions in smoking (83.3%), nicotine dependence (44.4%), and quit attempts (33.3%). Nine studies found the intervention condition achieved significantly higher smoking abstinence or reduction compared to the comparison group.

Conclusions and Implications

The most promising interventions in this review seem to be those that found significant between group differences and were rated as high methodological rigor. These interventions shared common elements, including being initiated while participants were admitted to inpatient psychiatric facilities, individualized to the participant, provided NRT, used technology (i.e., telephone or computer), contacted participants’ primary care providers to illicit support for smoking cessation, and had follow-up periods of at least 12 months. Clinical trial designs (e.g., SMART, factorial) that control for the provision of psychosocial medications and allow for the identification of optimal psychosocial treatments are needed. Future studies should also ensure greater inclusion of racial and ethnic minorities and sexual and gender minorities and should be culturally and linguistically adapted to improve treatment engagement and study outcomes.