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The Quit Experience and Concerns of Smokers With Psychiatric Illness

Open AccessPublished:December 17, 2015DOI:https://doi.org/10.1016/j.amepre.2015.11.006

      Introduction

      The purpose of this study is to better understand the quit experience and concerns of smokers with psychiatric illness (i.e., major depressive, anxiety, psychotic and bipolar disorders) in comparison with those without psychiatric illness.

      Methods

      Smokers (N=732) with (n=430, 59%) and without psychiatric illness, recruited between June 2010 and March 2013 to participate in the FLEX (Flexible and Extended Dosing of Nicotine Replacement Therapy [NRT] and Varenicline in Comparison to Fixed-Dose NRT for Smoking Cessation) smoking-cessation trial, completed questionnaires assessing previously used cessation aids and reasons for relapse, and motivation and concerns about their upcoming quit attempt. These supplementary data analyses were conducted in May 2015.

      Results

      The most commonly used cessation methods during previous attempts were nicotine replacement therapy (66.4%), cold turkey (59.7%), and bupropion (34.7%); no group differences were identified. Stress was the most common precipitator of relapse during previous attempts in all groups (43.6%), particularly among participants with depression and anxiety. Health was the most common motivation for the upcoming quit attempt (91%), followed by family/social pressures (28.1%) and cost (27.9%, particularly by smokers with psychotic disorders). Common pre-cessation concerns for the complete sample included: cravings (27.6%), stress (26.7%), and fear of failure (26%); participants with psychotic and anxiety disorders were most concerned about cravings, whereas the latter two concerns were more prominent for individuals with anxiety.

      Conclusions

      Findings reveal differences in the quit histories and concerns of smokers with or without psychiatric illness. Smokers with psychiatric illness are particularly vulnerable to relapse at times of stress and negative affect; interventions that emphasize alternative coping strategies and facilitate mood management are required.

      Introduction

      Tobacco addiction is the leading cause of preventable death worldwide.
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      To date, no study has compared cessation strategies between psychiatric and non-psychiatric patients.
      A fundamental understanding of the unique quitting experience of smokers with psychiatric illness could shape smoking-cessation interventions and relapse prevention programs so as to render them more effective. The purpose of the present study was to better understand the quit experiences of smokers with psychiatric illnesses in comparison with those without psychiatric comorbidities. Previously used cessation aids, reasons for relapse during past quit attempts, and the motivating factors and concerns that surround an upcoming cessation attempt were examined.

      Methods

      Participants and Procedures

      Treatment-seeking smokers from the general population were recruited between June 2010 and March 2013 by advertising, from physicians, by word of mouth, and through the quit smoking program at the University of Ottawa Heart Institute to participate in the FLEX (Flexible and Extended Dosing of NRT and Varenicline in Comparison to Fixed-Dose NRT for Smoking Cessation) trial.
      • Tulloch H.
      • Pipe A.
      • Els C.
      • et al.
      Flexible and extended dosing of nicotine replacement therapy or varenicline in comparison to fixed dose nicotine replacement therapy for smoking cessation: rationale, methods and participant characteristics of the FLEX trial.
      Inclusion criteria were: age ≥18 years, smoking ten or more cigarettes per day over the past 6 months, willingness to make a quit attempt within 2−4 weeks, and the ability to provide informed consent. Exclusion criteria included: current or past-month (>72 consecutive hours) use of the smoking-cessation pharmacologic interventions; having contraindications to the use of varenicline or NRT products; being pregnant, breastfeeding, or intending to become pregnant within the next year; current or previous (past 3 months) substance abuse; inability to provide informed consent owing to unstable psychiatric symptoms (i.e., active, untreated psychosis or suicidality); or an inability to read/write in English or French. Only one person per household could participate in the trial. The study received approval from the Ottawa Health Sciences Network Research Ethics Board.
      The present study includes supplementary analyses of data obtained during the baseline assessment of the FLEX trial. At baseline, participants engaged in a clinical psychiatric interview and completed questionnaires regarding demographic information, previous quit experiences, and motivation and concerns about an upcoming attempt (next 30 days).

      Measures

      Participants reported their age, gender, education, and marital and employment status. Smoking-related variables included the age at which participants smoked their first cigarette, years smoked, and number of quit attempts in the previous year. From a list of potential responses, participants reported which cessation aids they had used in the past for at least 24 hours for smoking cessation (e.g., cold turkey, NRT, hypnosis), reason(s) for relapsing to smoking (e.g., negative affect, other smokers, cravings), and motives (e.g., health, cost of cigarettes) and concerns (e.g., fear of failure, weight gain, stress) about the upcoming quit attempt.
      Participants were assessed for current or lifetime psychiatric history using the Mini International Psychiatric Interview 6.0.0,
      • Sheehan D.
      • Lecrubier Y.
      The Mini International Neuropsychiatric Interview Version 6.0 (MINI 6.0).
      • Sheehan D.V.
      • Lecrubier Y.
      • Sheehan K.H.
      • et al.
      The Mini-International Neuropsychiatric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10.
      a structured diagnostic interview used to assess DSM-IV and ICD-10 psychiatric disorders. Participants who did not meet any psychiatric diagnostic criteria in their lifetime were classified as “none,” whereas individuals who met lifetime (current or past) criteria were classified into one of four primary diagnoses: major depressive disorder, bipolar disorder, anxiety disorders (i.e., phobias, generalized anxiety disorder, post-traumatic stress disorder, panic disorder), and psychotic disorders. For individuals with comorbid diagnoses, the primary diagnosis was reviewed and determined by the study psychologist (HT) and psychiatrist (CE) using the following classification criteria:
      • 1.
        current superseded past diagnoses (e.g., current generalized anxiety and past major depression would be classified as an anxiety disorders);
      • 2.
        more severe superseded less severe diagnosis (e.g., comorbid psychotic and major depression would be classified as a psychotic disorder); and
      • 3.
        if equivalent in severity and duration (current/past), the disorder that warranted the most treatment attention and had the greatest impact on the participant’s functioning was classified as the primary diagnosis.

      Statistical Analysis

      Statistical analyses were conducted in May 2015. Initial comparisons between psychiatric groups were made for demographic and smoking history variables using ANOVA (with Tukey’s honest significant difference post-hoc test for group differences) for continuous measures and chi-square tests for categorical variables. Next, variables related to previous quit attempts and the upcoming quit attempt were compared for any psychiatric diagnosis versus no diagnosis using chi-square tests. In addition, the five psychiatric diagnosis groups (i.e., none, depression, anxiety, bipolar, and psychotic) were compared using chi-square tests; adjusted residuals (z-scores) were calculated for multiple comparisons (Bonferroni method, α=0.05) to determine which cells were significantly different. Previous quit attempt and upcoming quit attempt variables that were significantly different between the psychiatric diagnosis groups were then re-analyzed using a logistic regression (ref, no diagnosis), controlling for those demographic and smoking history variables that were significantly different in the initial analyses (AORs with 95% CIs). All analyses were conducted using SPSS, version 21, using an α of 0.05 to determine statistical significance.

      Results

      A total of 737 individuals participated; of these, 59% met diagnostic criteria for a psychiatric disorder. Owing to a very small sample size that restricted the power of comparisons to the other groups, participants who met diagnostic criteria for substance abuse in the previous 12 months (but not the last 3 months) alone were excluded from the analyses (n=5), leaving a final sample size of 732 smokers. A small number of participants (n=42) reported no previous quit attempts; these individuals were excluded from the analyses regarding previous quit attempts. In general, the sample comprised chronic smokers, smoking>23 cigarettes per day and having smoked for>31 years on average.
      Table 1 displays the participants’ demographic and smoking history by psychiatric diagnosis. The sample had a mean age of 48.6 (SD=10.83) years; individuals with anxiety disorders were slightly younger. The sample was fairly equally distributed across the sexes; individuals with a diagnosis of either depression, bipolar disorder, or anxiety were more likely to be female, whereas those with no diagnosis or psychotic disorders were more likely to be male. Approximately half of the sample (46%) was married or living with a partner. Individuals with no lifetime diagnosis were more likely to be married compared with those with bipolar or psychotic disorders; those diagnosed with depression tended to be separated, divorced, or widowed compared with those with no diagnosis; and those with a psychotic disorder were more likely to be single as compared with those with depression, anxiety, or no diagnosis. Participants had completed, on average, 14 years of formal education; participants with depression had less education than those in the nonpsychiatric group. The majority of the sample (61%) was employed full-time or part-time; those with any psychiatric diagnosis were more likely to be receiving disability benefits compared with those with no diagnosis. Participants with depression had smoked longer than those with anxiety (p=0.029). Participants with bipolar and psychotic disorders smoked significantly more cigarettes than did those with no diagnosis (p=0.025 and p<0.001, respectively).
      Table 1Demographics and Smoking History Variables by Psychiatric Diagnosis
      VariablesOverall (N=732)None (n=302)Any psychiatric diagnosis
      Compared with None (i.e., no diagnosis). HM, homemaker.
      (n=430)
      Depression (n=281)Anxiety (n=93)Bipolar disorders (n=38)Psychotic disorders (n=18)p-value
      Age (years), M (SD)48.61 (10.83)48.54 (11.01)48.63 (10.67)49.94 (10.59)45.48 (10.99)47.16 (9.25)48.61 (10.83)0.013
      Male, n (%)390 (53.3)188 (62.3)203 (47.6)132 (47.0)41 (44.1)14 (36.8)15 (83.3)<0.001
      Female, n (%)342 (46.7)114 (37.7)226 (52.4)149 (53.0)52 (55.9)24 (63.2)3 (16.7)
      Marital status, n (%)
       Single160 (22.0)52 (17.3)104 (25.2)57 (20.4)25 (20.9)14 (36.8)12 (70.6)<0.001
       Common law/married337 (46.3)172 (57.3)168 (38.8)110 (39.3)39 (41.9)14 (36.8)2 (11.8)
       Separated/divorced/widowed231 (31.7)76 (25.3)156 (36.0)113 (40.4)29 (31.2)10 (26.3)3 (17.7)
      Education (years), M (SD)14.13 (2.95)14.60 (2.81)13.79 (3.01)**13.78 (3.00)13.88 (3.22)13.55 (2.67)14.13 (2.95)0.008
      Employment, n (%)
       Working full- or part-time445 (61.1)226 (75.6)223 (51.4)149 (53.2)51 (54.8)15 (39.5)4 (22.2)<0.001
       Retired92 (12.6)41 (13.7)51 (11.8)38 (13.6)6 (6.5)5 (13.2)2 (11.1)
       Unemployed/HM66 (9.1)19 (6.4)47 (10.8)33 (11.8)10 (10.8)3 (7.9)1 (5.6)
       Disability leave125 (17.2)13 (4.3)113 (26.0)60 (21.4)26 (28.0)15 (39.5)11 (61.1)
      Smoking, M (SD)
       Age (years) at first cigarette14.48 (4.03)14.78 (4.3)14.26 (3.83)14.30 (4.1)14.11 (3.2)13.68 (3.0)15.72 (3.5)0.187
       Years smoked31.04 (11.7)30.84 (11.8)31.20 (11.59)32.43 (11.6)28.35 (11.5)30.74 (10.7)27.50 (11.41)0.031
       Cigarettes/day23.24 (10.8)21.96 (9.6)24.15 (11.38)*23.41 (10.1)23.34 (11.9)27.36 (14.5)33.18 (16.7)<0.001
       No. of quit attempts4.66 (5.83)4.52 (6.1)4.74 (6.20)4.95 (6.0)4.64 (5.1)3.64 (2.4)4.75 (5.9)0.752
      Note: Boldface indicates statistical significance (*p<0.01; **p<0.001). Statistical analyses conducted: ANOVA for continuous variables (age, education, age of first cigarette, years smoked, cigarettes/day, quit attempt); χ2 for categorical variables (gender, marital status, employment status).
      a Compared with None (i.e., no diagnosis). HM, homemaker.
      Table 2 displays the quit methods previously employed by participants. Transdermal NRT was the most common method used by all groups (69.5%), followed by cold turkey (62.6%), bupropion (36.1%), and NRT gum (35.7%). Group differences were observed in the use of bupropion (p=0.005), varenicline (p=0.017), and hypnosis (p=0.048) in the chi-square analyses, but were no longer significant after adjustment for confounding variables (all p-values>0.10). Few participants reported individual- or group-based smoking-cessation counseling (6%); no differences were found between groups in this regard.
      Table 2Quit Methods Used and Reasons Identified for Relapsing to Smoking During a Previous Quit Attempt by Psychiatric Diagnosis
      VariablesTotal sample,n (%) (N=689)None, n (%) (n=280)Any psychiatric diagnosis,
      Any psychiatric diagnosis analyses were analyzed in 2×2 contingency tables (no lifetime versus any lifetime diagnosis) and χ2 unadjusted p-values are presented.
      n (%) (n=409)
      Depression, n (%) (n=268)Anxiety disorder, n (%) (n=89)Bipolar disorder, n (%) (n=34)Psychotic disorder, n (%) (n=18)χ2 p-value
      χ2 unadjusted p-value reported for 5×2 tables (none, depression, bipolar, anxiety, psychotic diagnoses).
      LR adjusted p-value
      LR adjusted p-value=overall logistic regression adjusted p-value.
      Previous quit methods
       Patch479 (69.5)193 (69.6)286 (69.1)184 (68.7)59 (66.3)25 (73.5)13 (72.2)0.904
       Cold turkey431 (62.6)180 (64.3)253 (58.7)166 (61.9)56 (62.9)22 (64.7)7 (38.9)0.311
       Bupropion249 (36.1)122 (43.6)130 (30.0)***88 (32.8)26 (29.2)11 (32.4)2 (11.1)0.0050.245
       Gum246 (35.7)92 (32.9)156 (37.7)103 (38.4)29 (32.6)12 (35.3)10 (55.6)0.255
       Varenicline132 (19.2)54 (19.3)79 (19.1)64 (23.9)10 (11.2)2 (5.9)2 (11.1)0.0170.190
       Hypnosis124 (18.0)46 (17.1)78 (18.8)60 (22.4)13 (14.6)2 (5.9)1 (5.6)0.0480.172
       Inhaler98 (14.2)35 (12.9)63 (15.2)34 (12.7)18 (20.2)8 (23.5)2 (11.1)0.190
       Acupuncture66 (9.6)28 (10.0)38 (9.2)26 (9.7)10 (11.2)2 (5.9)0 (0)0.594
       Lozenge63 (9.1)23 (8.2)40 (9.7)28 (10.4)10 (11.2)0 (0)2 (11.1)0.307
       Laser47 (6.8)23 (8.52)25 (6.0)19 (7.1)4 (4.5)1 (2.9)0 (0)0.439
      Reasons for relapsing
       Stress314 (45.6)105 (38.2)
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      209 (50.5)**134 (50.0)
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      49 (55.1)
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      15 (44.1)
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      7 (38.9)
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      0.0410.038
       Other smokers256 (37.2)100 (36.4)156 (37.7)103 (38.4)34 (38.2)11 (32.4)5 (27.8)0.893
       Lack willpower255 (37.0)114 (41.5)
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      141 (34.1)*81 (30.2)
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      31 (34.8)
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      16 (47.1)
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      9 (50.0)
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      0.0320.109
       Cravings213 (30.9)82 (29.8)131 (31.6)78 (29.1)32 (36.0)13 (38.2)5 (27.8)0.759
       Negative affect185 (26.9)44 (15.7)
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      143 (34.5)***86 (32.1)
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      38 (42.7)
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      12 (35.3)
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      5 (27.8)
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      <0.001<0.001
       Social outings172 (25.0)74 (26.4)100 (24.2)65 (24.3)23 (25.8)7 (20.6)3 (16.7)0.696
       Drink alcohol149 (21.6)68 (24.3)85 (20.5)53 (19.8)16 (18.0)6 (17.6)6 (33.3)0.223
       After eating133 (19.3)52 (19.6)81 (19.6)46 (17.2)24 (27.0)6 (17.6)2 (11.1)0.736
       Boredom126 (18.3)47 (17.9)78 (18.8)45 (16.8)15 (16.9)12 (35.3)4 (22.2)0.203
       Drink caffeine111 (16.1)37 (13.5)74 (17.9)39 (14.6)21 (23.6)8 (23.5)4 (22.2)0.149
       Stopped cessation medications95 (13.7)38 (13.5)57 (13.8)41 (15.3)12 (13.5)3 (8.8)0 (0)0.608
      Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      Note: Boldface indicates statistical significance (*p<0.05; **p<0.01; ***p<0.001).
      a Any psychiatric diagnosis analyses were analyzed in 2×2 contingency tables (no lifetime versus any lifetime diagnosis) and χ2 unadjusted p-values are presented.
      b χ2 unadjusted p-value reported for 5×2 tables (none, depression, bipolar, anxiety, psychotic diagnoses).
      c LR adjusted p-value=overall logistic regression adjusted p-value.
      d,e Column proportions (for each row) that differ significantly from each other, corrected for multiple comparisons using Bonferroni adjustment (p<0.05) for the 5 psychiatric groups. LR, logistic regression.
      Reasons for a relapse to smoking are presented in Table 2. Stress was the most common response in all groups (endorsed by 45.6%). Stress and negative affect were significantly different between those with and without any lifetime diagnosis (p-values ≤0.01). Compared with those with no diagnosis, stress was more likely to be endorsed by those with depression (AOR=1.55, 95% CI=1.08, 2.23) and anxiety (AOR=1.83, 95% CI=1.12, 3.05); negative affect was more likely to be endorsed by those with depression (AOR=2.41, 95% CI=1.56, 3.72), bipolar disorder (AOR=2.79, 95% CI=1.25, 6.21), and anxiety (AOR=3.60, 95% CI=2.06, 6.29). Those with no psychiatric diagnosis were more likely to report lack of willpower as a reason for relapse compared with individuals with depression (AOR=0.61, 95% CI=0.42, 0.88). Being alone, weight gain, seeing smoking stimuli (e.g., cigarettes), and when relaxing were endorsed by <10% of the sample as contributing to relapse; no differences between groups were revealed.
      Participants endorsed various reasons for quitting (Table 3). Overall, health was the most common response (91%), followed by family/social pressures (28.1%) and cost of cigarettes (27.9%). Those with a psychotic disorder were more likely to report the cost of cigarettes as a reason to quit when compared with those with no diagnosis (AOR=3.21, 95% CI=1.11, 9.30). Those with no diagnosis were more likely to report others’ health (e.g., for a child or partner) as a reason to quit smoking compared with individuals with depression (AOR=0.56, 95% CI=0.35, 0.91).
      Table 3Most Endorsed Reasons for Quitting and Concerns About Quitting for Upcoming Quit Attempt by Psychiatric Diagnosis
      VariablesTotal sample, n (%) (n=732)None, n (%) (n=302)Any psychiatric diagnosis,
      Any psychiatric diagnosis analyses were analyzed in 2×2 contingency tables (no lifetime versus any lifetime diagnosis) and χ2 unadjusted p-values are presented.
      n (%) (n=430)
      Depression, n (%) (n=281)Anxiety disorder, n (%) (n=93)Bipolar disorder, n (%) (n=38)Psychotic disorder, n (%) (n=18)χ2 p-value
      χ2 unadjusted p-value reported for 5×2 tables (none, depression, bipolar, anxiety, psychotic diagnoses).
      LR adjusted p-value
      LR adjusted p-value=overall logistic regression adjusted p-values.
      Reasons for quitting
       Health662 (90.9)270 (89.7)396 (91.7)252 (90.3)89 (96.7)33 (86.8)18 (100)0.135
       Family/social pressure203 (28.1)80 (27.0)125 (28.9)80 (28.7)28 (30.4)11 (28.9)4 (22.2)0.952
       Cost204 (28.0)72 (23.9)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      134 (31.0)81 (29.0)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      29 (31.5)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      ,
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      11 (28.9)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      ,
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      11 (61.1)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      0.0110.024
       Others’ health120 (16.5)61 (20.3)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      63 (14.6)35 (12.5)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      19 (20.7)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      5 (13.2)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      0 (0)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      0.023
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      0.016
       Doctor’s advice103 (14.1)41 (13.6)62 (14.4)35 (12.5)16 (17.4)7 (18.4)4 (22.2)0.569
       Other68 (9.3)33 (11.0)35 (8.1)27 (9.7)5 (5.4)2 (5.3)1 (5.6)0.452
       Athletic activities51 (7.0)17 (5.6)34 (7.9)23 (8.2)8 (8.7)1 (2.6)2 (11.1)0.475
       Stress37 (5.1)11 (3.7)27 (6.2)14 (5.0)9 (9.8)1 (2.6)2 (11.1)0.112
       Smell or taste31 (4.2)13 (4.2)18 (4.1)11 (3.9)3 (3.2)3 (7.9)1 (5.6)0.811
      Fisher’s exact test p-value (>20% of cases with expected count <5). LR, logistic regression.
      Concerns about quitting
       Cravings201 (27.6)75 (24.9)128 (29.7)76 (27.2)29 (31.9)11 (28.9)10 (55.6)0.061
       Stress195 (26.8)66 (21.9)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      131 (30.4)75 (26.9)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      41 (45.1)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      7 (18.4)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      6 (33.3)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      ,
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      <0.0010.001
       Fear of failure188 (25.9)68 (22.6)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      120 (27.8)74 (26.5)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      ,
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      34 (37.4)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      10 (26.3)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      ,
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      2 (11.1)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      ,
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      0.0390.038
       Weight gain153 (21.0)66 (21.9)88 (20.4)60 (21.5)19 (20.9)5 (13.2)3 (16.7)0.771
       Mood136 (18.7)46 (15.3)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      91 (21.1)45 (16.1)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      28 (30.8)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      11 (28.9)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      ,
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      6 (33.3)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      ,
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      0.0020.006
       Willpower122 (16.8)50 (16.6)72 (16.7)45 (16.2)18 (19.8)5 (13.2)4 (22.2)0.844
       Other smokers116 (16.0)38 (12.6)78 (18.1)52 (18.6)16 (17.6)5 (13.2)5 (27.8)0.180
       Boredom71 (9.8)20 (6.6)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      52 (12.1)29 (10.4)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      ,
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      14 (15.4)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      ,
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      3 (7.9)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      5 (27.8)
      Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      0.0090.007
       Other58 (8.0)25 (8.3)33 (7.7)20 (7.2)7 (7.7)6 (15.8)0 (0)0.285
       Celebration57 (7.8)24 (8.0)33 (7.7)20 (7.2)8 (8.8)3 (7.9)2 (11.1)0.967
      Note: Boldface indicates statistical significance (p<0.05).
      a Any psychiatric diagnosis analyses were analyzed in 2×2 contingency tables (no lifetime versus any lifetime diagnosis) and χ2 unadjusted p-values are presented.
      b χ2 unadjusted p-value reported for 5×2 tables (none, depression, bipolar, anxiety, psychotic diagnoses).
      c LR adjusted p-value=overall logistic regression adjusted p-values.
      d,e Column proportions (for each row) that differ significantly (z-test) from each other, corrected for multiple comparisons using Bonferroni adjusted p-values.
      f Fisher’s exact test p-value (>20% of cases with expected count <5). LR, logistic regression.
      Table 3 also displays the participants’ concerns about their upcoming quit attempt. Cravings were the most common concern for smokers in this study (27.6%), followed closely by stress (26.7%) and fear of failure (26%). Compared with those with no diagnosis, those with anxiety disorders were more likely to report stress (AOR=3.27, 95% CI=1.93, 5.56), fear of failure (AOR=2.23, 95% CI=1.30, 3.83), and mood (AOR=2.31, 95% CI=1.29, 4.13) as concerns for quitting. Smokers with psychotic disorders were also more likely to endorse craving as a concern (AOR=4.16, 95% CI=1.44, 12.06), and boredom was a significant concern for those with anxiety (AOR=2.75, 95% CI=1.29, 5.90) and psychotic disorders (AOR=8.03, 95% CI=2.25, 28.69) as compared with those with no diagnosis. A small percentage of participants (<2%) were concerned about missing the enjoyment of smoking, managing smoking-cessation medications, and when drinking or eating.

      Discussion

      Promoting smoking cessation is a global public health priority. Smokers with psychiatric diagnoses represent a growing proportion of the smoking population, suffer from smoking-related diseases at a disproportionate rate, and require improved intervention efforts.
      • Lê Cook B.
      • Wayne G.F.
      • Kafali E.N.
      • Liu Z.
      • Shu C.
      • Flores M.
      Trends in smoking among adults with mental illness and association between mental health treatment and smoking cessation.
      An understanding of their cessation concerns and experiences is particularly important if clinicians are to be more effective in stimulating and supporting their cessation attempts. The present study is one of few to have investigated the quit experience and concerns of smokers with and without a psychiatric diagnosis,
      • Weinberger A.H.
      • George T.P.
      • McKee S.A.
      Differences in smoking expectancies in smokers with and without a history of major depression.
      mental health patients’ reasons to consider quitting and for relapse, and it is the first study to include a sample presenting with various psychiatric diagnoses. The findings indicate that important differences exist in the quit experiences and perceptions between these groups of smokers.
      The number one quit method for all smokers was NRT. With the exception of slightly higher rates of bupropion use, the results presented herein are similar to general population data from the United Kingdom reporting that 68%−78% of smokers used NRT, 5%−8% tried bupropion, and 14%−26% used varenicline.
      • Gunnell D.
      • Irvine D.
      • Wise L.
      • Davies C.
      • Martin R.M.
      Varenicline and suicidal behaviour: a cohort study based on data from the General Practice Research Database.
      • Thomas K.H.
      • Martin R.M.
      • Davies N.M.
      • Metcalfe C.
      • Windmeijer F.
      • Gunnell D.
      Smoking cessation treatment and risk of depression, suicide, and self harm in the Clinical Practice Research Datalink: prospective cohort study.
      On one hand, these results are encouraging—all groups have used a variety of cessation products that have proven effective for smoking cessation.
      • Fiore M.
      • Jaen C.
      • Baker T.
      Treating Tobacco Use and Dependence: 2008 Update: Clinical Practice Guideline.
      On the other hand, more than half of the sample tried to quit “cold turkey.” U.S. national data also show limited use of cessation treatments.
      • Shiffman S.
      • Brockwell S.E.
      • Pillitteri J.L.
      • Gitchell J.G.
      Use of smoking-cessation treatments in the United States.
      To curb craving and withdrawal symptoms, clinicians should be encouraged to prescribe pharmacotherapy for smokers wanting to quit. Population-level studies, clinical databases, and recent RCTs have provided assurance that these medications do not lead to any worsening of psychiatric symptoms.
      • Gunnell D.
      • Irvine D.
      • Wise L.
      • Davies C.
      • Martin R.M.
      Varenicline and suicidal behaviour: a cohort study based on data from the General Practice Research Database.
      • Thomas K.H.
      • Martin R.M.
      • Davies N.M.
      • Metcalfe C.
      • Windmeijer F.
      • Gunnell D.
      Smoking cessation treatment and risk of depression, suicide, and self harm in the Clinical Practice Research Datalink: prospective cohort study.
      • Pasternak B.
      • Svanström H.
      • Hviid A.
      Use of varenicline versus bupropion and risk of psychiatric adverse events.
      Data from the present study suggest that smokers, especially those with a lifetime diagnosis of major depressive and anxiety disorders, report stress and negative affect as common precursors to relapse. These results are consistent with previous publications with general
      • Vangeli E.
      • Stapleton J.
      • West R.
      Smoking intentions and mood preceding lapse after completion of treatment to aid smoking cessation.
      • Kassel J.D.
      • Stroud L.R.
      • Paronis C.A.
      Smoking, stress, and negative affect: correlation, causation, and context across stages of smoking.
      • Kenford S.L.
      • Smith S.S.
      • Wetter D.W.
      • Jorenby D.E.
      • Fiore M.C.
      • Baker T.B.
      Predicting relapse back to smoking: contrasting affective and physical models of dependence.
      and mental health populations.
      • Cooper J.
      • Mancuso S.G.
      • Borland R.
      • Slade T.
      • Galletly C.
      • Castle D.
      Tobacco smoking among people living with a psychotic illness: the second Australian Survey of Psychosis.
      • Solway E.S.
      The lived experiences of tobacco use, dependence, and cessation: insights and perspectives of people with mental illness.
      Research shows that all smokers, but especially those with psychiatric disorders, retain the belief that smoking produces positive emotional states (e.g., relaxation, pleasure)
      • Piper M.E.
      • Smith S.S.
      • Schlam T.R.
      • et al.
      Psychiatric disorders in smokers seeking treatment for tobacco dependence: relations with tobacco dependence and cessation.
      • Weinberger A.H.
      • Desai R.A.
      • McKee S.A.
      Nicotine withdrawal in US smokers with current mood, anxiety, alcohol use, and substance use disorders.
      ; it is not surprising that negative affect often precedes a lapse in smoking cessation. It has been suggested that the perceived benefits of smoking when stressed are a misattribution of nicotine withdrawal relief.
      • DiFranza J.R.
      • Wellman R.J.
      A Sensitization—homeostasis model of nicotine craving, withdrawal, and tolerance: integrating the clinical and basic science literature.
      Future interventions would do well to emphasize the importance of identifying negative mood as a time of vulnerability and equip smokers with alternative, healthy coping mechanisms. Clinicians need to debunk the misinformation and misperceptions of the expectancies of smoking. For example, emerging evidence demonstrates that anxiety and depression symptoms actually decrease, and psychotic symptoms remain stable with abstinence.
      • McDermott M.S.
      • Marteau T.M.
      • Hollands G.J.
      • Hankins M.
      • Aveyard P.
      Change in anxiety following successful and unsuccessful attempts at smoking cessation: cohort study.
      • Ragg M.
      • Gordon R.
      • Ahmed T.
      • Allan J.
      The impact of smoking cessation on schizophrenia and major depression.
      • Taylor G.
      • McNeill A.
      • Girling A.
      • Farley A.
      • Lindson-Hawley N.
      • Aveyard P.
      Change in mental health after smoking cessation: systematic review and meta-analysis.
      An educational component that highlights the psychological benefits of abstinence and challenges the positive expectations of smoking might add value to cessation interventions.
      Results showed that smokers with psychiatric diagnoses attempted to quit at similar rates as those without psychiatric comorbidity. The most common reasons to quit reported by the current sample included health, social or family pressure, cost of cigarettes, and other’s health. Participants with psychotic disorders were particularly motivated by financial concerns; this finding is expected considering that psychiatric patients tend to be low-income and in receipt of disability benefits. The results also corroborate previous findings that health is an important motivator to quit smoking among all smokers.
      • McCaul K.D.
      • Hockemeyer J.R.
      • Johnson R.J.
      • Zetocha K.
      • Quinlan K.
      • Glasgow R.E.
      Motivation to quit using cigarettes: a review.
      • Dickerson F.
      • Bennett M.
      • Dixon L.
      • et al.
      Smoking cessation in persons with serious mental illnesses: the experience of successful quitters.
      • Filia S.L.
      • Baker A.L.
      • Gurvich C.T.
      • Richmond R.
      • Kulkarni J.
      The perceived risks and benefits of quitting in smokers diagnosed with severe mental illness participating in a smoking cessation intervention: gender differences and comparison to smokers without mental illness.
      • Ashton M.
      • Rigby A.
      • Galletly C.
      What do 1000 smokers with mental illness say about their tobacco use?.
      However, it is important to note that psychotic patients in a previous study reported lower perceived health risks with smoking than did nonpsychiatric controls
      • Kelly D.L.
      • Raley H.G.
      • Lo S.
      • et al.
      Perception of smoking risks and motivation to quit among nontreatment-seeking smokers with and without schizophrenia.
      ; interventions are needed to address this misconception.
      Despite their motivation to quit, psychiatric patients, especially those with anxiety and psychotic disorders, expressed many concerns in the weeks before a target quit date. As reported in the general population,
      • Allen S.S.
      • Bade T.
      • Hatsukami D.
      • Center B.
      Craving, withdrawal, and smoking urges on days immediately prior to smoking relapse.
      craving is a key concern for smokers with psychiatric disorders. Clinicians would do well to offer pharmacotherapy to all smokers
      • Fiore M.
      • Jaen C.
      • Baker T.
      Treating Tobacco Use and Dependence: 2008 Update: Clinical Practice Guideline.
      and to draw attention to the efficacy of these products in managing craving and the symptoms of withdrawal and enhancing the likelihood of successful cessation. Participants, particularly those with anxiety disorders, were worried about coping with stress, fear of failure, and mood changes when attempting to quit. Other researchers have also reported a fear of deteriorating mental health (e.g., worry about increasing anxiety levels) and loss of a coping strategy as concerns about quitting within this population.
      • Kerr S.
      • Woods C.
      • Knussen C.
      • Watson H.
      • Hunter R.
      Breaking the habit: a qualitative exploration of barriers and facilitators to smoking cessation in people with enduring mental health problems.
      Those with psychiatric conditions contemplating and attempting cessation should be provided with cessation aids, support, and more-clearly articulated strategies for stress management. Mental health patients themselves have expressed interest in additional professional support and better mood management during a quit attempt.
      • Clancy N.
      • Zwar N.
      • Richmond R.
      Depression, smoking and smoking cessation: a qualitative study.
      More intensive and integrated smoking-cessation interventions for psychiatric patients may be required.
      • Lê Cook B.
      • Wayne G.F.
      • Kafali E.N.
      • Liu Z.
      • Shu C.
      • Flores M.
      Trends in smoking among adults with mental illness and association between mental health treatment and smoking cessation.
      • McFall M.
      • Saxon A.J.
      • Malte C.A.
      • et al.
      Integrating tobacco cessation into mental health care for posttraumatic stress disorder: a randomized controlled trial.

      Limitations

      Despite the strengths of the present study, it is not without limitations. First, the data are cross-sectional, prohibiting causal inferences. Second, the quit methods and relapse data are retrospective and may be influenced by recall or subjective biases. There are secular factors, which may have influenced the use of certain cessation pharmacotherapies in the past (e.g., cost and availability); evolving evidence of the safety and suitability of certain pharmacotherapies may also have been reflected in the reported use of such treatments in the past. Third, relative to the other groups, the sample of participants with bipolar and psychotic disorders was small and may have limited the understanding of factors relevant to cessation attempts and success within this important patient population. Finally, given that the participants were treatment-seeking smokers with previous quit experience, the generalizability of the results to a broader population of smokers with comorbid conditions is unknown.

      Conclusions

      In summary, differences in the quit histories and concerns of smokers with or without psychiatric illness are evident. Smokers with psychiatric illness are particularly vulnerable to relapse at times of stress and negative affect; interventions that facilitate mood management are required.

      Acknowledgments

      This project is supported by the Heart and Stroke Foundation of Ontario (GIA#6614). M. Clyde is supported by an Ontario Graduate Scholarship. The FLEX trial was registered on Clinical Trials.gov (identifier# NCT01623505).
      No financial disclosures were reported by the authors of this paper.

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