Background and Significance
The high rate of combustible tobacco use among persons with schizophrenia, affective, post
traumatic stress and substance misuse disorders is well documented. Over 40% of the estimated
9.8 million Americans, or 4.0% of the total population, who have serious behavioral health
disorders smoke cigarettes, at a rate two to three times higher than the general population.
The adverse health consequences and abbreviated lifespan for these persons is also well
documented. Given the greater rate of tobacco use, persons with behavioral health disorders
are at greater risk for morbidity, e.g., respiratory and cardio-vascular illness, and
pre-mature mortality. The relationship of individuals in these communities to combustible
tobacco in its pharmacological, sensorimotor and behavioral aspects is compelling. There is a
significant literature documenting the endorsement and benefit of nicotine and smoking
behavior for individuals in these communities.
Clinical or personal context contribute to the barriers in making change, e.g., the social
acceptability of smoking, lack of support, poor access to interventions, the need to mitigate
stress and other symptoms of serious mental illness. The need for meaningful structure and
daily engagement leads many to use tobacco to fill time and as a distraction. However, many
individuals express a desire to quit or further reduce their tobacco consumption.
Conventional tobacco interventions and approaches, e.g., smoking cessation, quit lines,
informal telephone counseling, FDA approved Nicotine Replacement Therapies (NRTs) and
medications have limited documented success. Existing evidence indicates that the combination
of pharmacological intervention along with behavioral support is superior to either of these
interventions alone. However the behavioral support aspect is usually limited to four to
eight sessions.
Local Need
As documented by the State,California has led the way in the progressive decrease in
combustible tobacco use. San Francisco County has a 10.8% rate of smoking. Over 25,000 adults
received service on an annual basis from the San Francisco Department of Public Health. Of
these service recipients at least 6028 adults or 24% (18 or older) are smokers, 5722 persons
report having never smoked and for another 7926 (31.5%) smoking status is unknown. The larger
department of public health offers smoking cessation services however there are no dedicated
services targeting the behavioral health service user. Tobacco use is increasingly of concern
for behavioral health program administrators and managers. Recruitment of programs for this
research effort was met with enthusiasm and an unambiguous expression of a need for an
intensive, harm reduction approach to tobacco intervention. The local Health Department
division of Behavioral Health Services maintains a dedicated Harm Reduction policy regarding
substance use behaviors.
Consultants were retained to conduct, record and analyze the experience, barriers, challenges
and satisfaction with smoking and smoking cessation attempts for individuals with behavioral
health disorders through the facilitation of four focus groups. In summary, focus group
participants report an understanding of smoking as an addiction integral to their daily
lives; that its pleasurable effects override health concerns; that cigarettes are a "friend"
and something to pass time and overcome boredom; that they understood restrictions on smoking
but also feel harassed or demeaned for smoking; and that not smoking requires "willpower"
against a powerful addiction. Some felt that a "harm reduction" approach, e.g., gradual
reduction was best and most acknowledge that relapse was a common experience. There was a
wealth of experience with smoking cessation and a diversity of satisfaction with various
intervention strategies. Gum and patch were generally reported as not satisfying; Chantix was
found to be helpful and a curiosity about inhaler or vaping as long as it is safe.
Individuals also reported on personal strategies to help with reduction or cessation. More
generally, individuals wanted more information about the range of choices. Some noted that
access through insurance was a barrier except for those who had both Medicaid and Medicare.
It is notable that participants report that they did not appreciate preaching or lecturing
about the need to stop smoking. The conclusion is that individuals express a desire to reduce
or abstain from tobacco use and also express the need for more help in doing so. Interest in
the various intervention choices is diverse however gradual reduction with some aide appears
to be the modal choice.
Hypotheses
A Harm Reduction approach will result in a decrease in daily combustible tobacco use
when compared to baseline use.
Support and harm reduction approaches will be important to acceptability.
Research Questions
Does this Harm Reduction approach reduce combustible tobacco use when compared to
baseline use?
Which strategies or combination of strategies demonstrate a greater or lesser impact in
combustible tobacco use?
At what service intensity points, e.g., intervention dose as defined by number of weeks,
does combustible tobacco use decrease?
To what degree does this Harm Reduction approach retain individuals in this
intervention, i.e., acceptability of intervention?
What are participants' experiences with factors that enable success or barriers?