Building a Research Agenda for Reducing Smoking and Other Cardiovascular Risk Factors

It has been more than a decade since the National Association of State Mental Health Program Directors (NASMHPD) published their influential work demonstrating 25 years of life lost among people with serious mental illness in the United States, largely due to the effects of cardiovascular disease (NASMHPD Medical Directors Council, 2006). Similar morbidity and mortality in these populations has been reported worldwide in developed nations. Since then, awareness of the issue has increased dramatically among mental health care consumers, providers, and other key stakeholders. Yet efforts to impact the population and enhance outcomes do not seem to come fast enough. The complexity of the multiple issues is surely a factor, as is overcoming systematic barriers such as the traditional separation of mental from physical health care. Impacting tobacco use and helping patients to quit smoking have the greatest impact on reducing risk of cardiovascular disease yet are often the most challenging to put into practice. Indeed, a national effort in the United States to address cardiovascular risk reduction has yielded only modest reductions in blood pressure and cholesterol levels, with less success in helping clients reduce weight or stop smoking (Scharf et al., 2016; Scharf et al., 2013).

This issue of the Journal of Dual Diagnosis explores the problem of addressing cardiovascular risk factors in people living with mental illness or alcohol and other drug use disorders. We were pleased that the call for papers revealed so much research activity in addressing tobacco, since that was not a requirement and tobacco smoking has received comparatively less clinical and research attention. Ongoing successful public health efforts to reduce tobacco use in the general population are having less impact on seriously mentally ill populations, suggesting that novel and innovative approaches will be needed. This issue covers the spectrum of areas for further exploration from research to better understanding biobehavioral links between smoking and mental illness to evaluating the impact of novel clinical innovations.

The paper by Carroll and colleagues adds to their earlier reports linking depression and smoking with coronary artery calcification (CAC), a measure of subclinical atherosclerosis and risk factor for serious cardiac events. This analysis, using data from the nationally representative CARDIA (Coronary Artery Risk Development in Young Adults) study, showed associations among a specific depression symptom subgroup (somatic), smoking, and CAC, with the strongest association found among participants with the greatest levels of smoking exposure. Prior studies have also found that somatic symptoms of depression (changes in appetite, sleep problems) are most strongly associated with cardiovascular disease. As the authors state, with the growing evidence that depression may be an independent risk factor for cardiovascular disease, further clarification of these complex relationships is essential.

Australian researchers have long led innovations in addressing tobacco in populations with mental illness or substance use disorders and many contribute as coauthors in this special issue. The paper by Ingram and colleagues examines smoking patterns among people attending residential substance abuse treatment. This paper highlights the refractory nature of smoking in this population when only low-intensity services are provided. One possible explanation offered by the authors for the high rates of continued smoking was the presence of smoking by others and lack of a tobacco-free policy, which is known to have a strong impact on reducing smoking in other populations. Of importance, this paper also adds to a growing body of evidence linking quitting smoking to greater abstinence from drugs and alcohol.

Perceptions of health risk are an important factor in understanding motivation to quit smoking or change other health behaviors, yet Kowalczyk and colleagues found that smokers with schizophrenia were less likely to completely recognize health risks of smoking. They also found that smokers with schizophrenia were heavier smokers with more pulmonary disease compared to controls, strongly underscoring a need for more health education as part of a successful intervention.

Success rates in smoking cessation studies in psychotic populations have been lower than in the general population, yet further analyses of these studies can provide clues for future efforts through examining predictors of outcome. In particular, much attention has been given to theories that smokers with schizophrenia smoke for “stimulation,” as a way to enhance attention or concentration or to overcome the effects of antipsychotic medications. Clark and colleagues examined self-reported reasons for smoking and found smoking for stimulation/activation to be related to outcome and inversely related to symptoms and functional level, suggesting that it may be an important outcome measure to include in future studies.

The role of antipsychotics in contributing to and worsening substance use in psychotic populations has been long debated. In a cohort of smokers with schizophrenia, Wehring and colleagues found no overall difference in tobacco craving between individuals in groups receiving different antipsychotics. This adds to literature suggesting few if any differences between older typical antipsychotics and newer atypical antipsychotics, despite proposed differences in receptor activity.

In a study exploring the relationship between social anxiety and smoking-specific experiential avoidance (the tendency to inflexibly respond to aversive internal stimuli via smoking), Watson and colleagues in this issue conducted a secondary analysis from a larger cessation study. A strength of the study was the inclusion of important covariates such as levels of nicotine dependence, depression, generalized anxiety, and posttraumatic stress disorder (PTSD).

They found that higher levels of baseline social anxiety were associated with greater levels of smoking-specific experiential avoidance to physical, emotional, and cognitive cues. Treatment implications include enhancing ways to assist anxious smokers to accept cues without responding.

Hicks and colleagues also focused on smokers with anxiety, pilot-testing a smartphone-based smoking cessation application in PTSD, finding that it was feasible and acceptable. Certainly there is much interest in developing adjunctive treatment that can be delivered in a cost-effective way using technology, and there are plans to evaluate the technology further in a larger clinical trial.

Other groups are showing promising results from specialty tobacco treatment services for clients with mental illness or substance use disorder. These services are often characterized by more sessions than a traditional counseling approach and increased access to pharmacotherapy treatments. Okoli and colleagues reported on real-world findings of treatment outcomes including use of pharmacotherapy. Individuals who had their pharmacotherapy switched during treatment were characterized by higher levels of dependence and less success in quitting.

Although smoking levels are dropping in adolescents, there is a need to identify those at high risk. Having a behavioral health condition such as depression, attention deficit disorder, or even conduct disorder is associated with a higher risk in the progression to daily smoking and nicotine dependence among youth. Aloise-Young and colleagues evaluated the relation between internalizing problem behaviors and early adolescent cigarette smoking and showed a complex relationship that changed over time. That is, internalizing may act as a protective factor for some youth leading to less smoking but then shift to being a risk factor for those youth who experiment with smoking, if they experience a reduction in anxiety. The conflicting research in this area and complexity of findings support the need for a larger, longitudinal study.

Esteemed colleague Sharon Lawn has been a champion in challenging the status quo of smoking in behavioral health treatment facilities and she and colleagues provide an innovative commentary of the role of family caregivers as a part of the plan to address tobacco use in individuals with serious mental illness. Previously overlooked, the family caregiver has many advantages in being able to assist a mental health care consumer in important lifestyle and health changes. Although there is a need to balance efforts with caregivers' concerns about navigating these relationships, this report convincingly argues that this approach warrants further study.

Telephone quitlines are an effective means to deliver smoking cessation counseling, although questions exist as to their appropriateness for smokers with serious mental illness. Recognizing the needs of callers with mental illness, Segan and colleagues implemented structured assessments for nicotine withdrawal symptoms and medication side effects that were ultimately valued by both quitline counselors and clients. Given evidence of its benefits in this limited pilot study, we recommend that it be considered for larger-scale adoption by quitlines.

We are excited and enthused by these new reports that can further stimulate efforts in this area and shape a research agenda for the future. We are hopeful that this knowledge contributes to more efforts to reduce smoking and cardiovascular disease risk in individuals with mental illness and substance use disorders. Despite the barriers that exist, there is growing evidence that these interventions do not worsen symptoms and are nearly always beneficial. By understanding more about the complex biobehavioral factors, interventions will be able to be more suitably tailored and effectively delivered. We look forward to the day when this is simply the standard of care worldwide.

Disclosures

Amanda Baker has received nicotine replacement therapy from GlaxoSmithKline in randomized controlled trials.