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Original Investigation
May 5, 2021

Sustained Care Smoking Cessation Intervention for Individuals Hospitalized for Psychiatric Disorders: The Helping HAND 3 Randomized Clinical Trial

Author Affiliations
  • 1School of Nursing, University of Texas at Austin, Austin
  • 2Department of Psychology, Fordham University, Bronx, New York
  • 3Center for Alcohol and Addiction Studies, Brown University School of Public Health, Providence, Rhode Island
  • 4Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, Rhode Island
  • 5Butler Hospital, Alpert Medical School of Brown University, Providence, Rhode Island
  • 6Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
  • 7Seton Shoal Creek Hospital, Austin, Texas
  • 8Department of Psychiatry, Dell Medical School at the University of Texas at Austin, Austin
  • 9Rhode Island Hospital, Providence, Rhode Island
  • 10Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, Rhode Island
  • 11Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island
  • 12Tobacco Research and Treatment Center, Massachusetts General Hospital, Harvard Medical School, Boston
  • 13Mongan Institute Health Policy Research Center, Department of Medicine, Massachusetts Medical School, Harvard Medical School, Boston
  • 14Center for Wellbeing Research, Optum, Seattle, Washington
  • 15Department of Psychiatry, Dell Medical School, University of Texas at Austin, Austin
  • 16Department of Health Social Work, Steve Hicks School of Social Work, University of Texas at Austin, Austin
  • 17Department of Psychology, University of Texas at Austin, Austin
JAMA Psychiatry. Published online May 5, 2021. doi:10.1001/jamapsychiatry.2021.0707
Key Points

Question  Can a brief, multicomponent, sustained care smoking cessation intervention tailored to individuals with severe mental illness facilitate treatment engagement and abstinence following hospital discharge?

Findings  In this randomized clinical trial involving 353 adults with severe mental illness who reported smoking cigarettes, a sustained care smoking cessation intervention yielded greater treatment engagement and abstinence at 6 months following discharge than usual care.

Meaning  In this study, intervening during the psychiatric hospital stay using a patient-centered approach was effective at continuing the move toward smoking abstinence initiated during the hospital stay.


Importance  Smoking among individuals with serious mental illness (SMI) represents a major public health problem. Intervening during a psychiatric hospital stay may provide an opportunity to aid engagement in smoking cessation treatment and facilitate success in quitting.

Objective  To examine the effectiveness of a multicomponent, sustained care (SusC) smoking cessation intervention in adults with SMI receiving inpatient psychiatric care.

Design, Setting, and Participants  The Helping HAND 3 randomized clinical trial compared SusC with usual care (UC) among individuals with SMI who smoked daily and were receiving inpatient psychiatric care in Austin, Texas, in a single hospital. The study was conducted from July 2015 through August 2019.

Interventions  The UC intervention involved brief smoking cessation information, self-help materials and advice from the admitting nurse, and an offer to provide nicotine replacement therapy during hospitalization. The SusC intervention included 4 main components designed to facilitate patient engagement with postdischarge smoking cessation resources: (1) inpatient motivational counseling; (2) free transdermal nicotine patches on discharge; (3) an offer of free postdischarge telephone quitline, text-based, and/or web-based smoking cessation counseling, and (4) postdischarge automated interactive voice response calls or text messages.

Main Outcomes and Measures  The primary outcome was biochemically verified 7-day point-prevalence abstinence at 6-month follow-up. A secondary outcome was self-reported smoking cessation treatment use at 1, 3, and 6 months after discharge.

Results  A total of 353 participants were randomized, of whom 342 were included in analyses (mean [SD] age, 35.8 [12.3] years; 268 White individuals [78.4%]; 280 non-Hispanic individuals [81.9%]; 169 women [49.4%]). They reported smoking a mean (SD) of 16.9 (10.4) cigarettes per day. Participants in the SusC group evidenced significantly higher 6-month follow-up point-prevalence abstinence rates than those in the UC group (8.9% vs 3.5%; adjusted odds ratio, 2.95 [95% CI, 1.24-6.99]; P = .01). The number needed to treat was 18.5 (95% CI, 9.6-306.4). A series of sensitivity analyses confirmed effectiveness. Finally, participants in the SusC group were significantly more likely to report using smoking cessation treatment over the 6 months postdischarge compared with participants in the UC group (74.6% vs 40.5%; relative risk, 1.8 [95% CI, 1.51-2.25]; P < .001).

Conclusions and Relevance  The findings of this randomized clinical trial provide evidence for the effectiveness of a scalable, multicomponent intervention in promoting smoking cessation treatment use and smoking abstinence in individuals with SMI following hospital discharge.

Trial Registration  ClinicalTrials.gov Identifier: NCT02204956

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    1 Comment for this article
    Professional smoking rooms in psychiatric wards: behavioral support of nicotine replacement therapy.
    Napoleon Waszkiewicz, Professor | Department of Psychiatry, Medical University of Białystok
    While reading Brown and Colleagues article (1) I had an overwhelming impression that, according to the authors' feelings, helping psychiatrically hospitalized patients to stop smoking should be the responsibility of the psychiatrists working there. The authors' work on scalable and multicomponent intervention contributes a lot to research on the promotion of anti-smoking activities. However, the statement that no tobacco use is allowed on psychiatric hospital units may be misleading. While this is the case in some countries, some still allow or even recommend the construction of professional smoking rooms in psychiatric wards, similarly to the creation of dedicated smoking places in public spaces around the world (2,3). Moreover, patients are often permitted to smoke outside (2).
    Harm reduction programs remain standard in psychiatry for decades, also for nicotine use (nicotine replacement therapy -NRT), and allow the final discontinuation of the substance (4).
    In 2016, in Poland, thanks to the efforts of the Patient Ombudsman, the provisions regarding the presence of smoking rooms in psychiatric hospitals were amended. The possibility of designating smoking rooms in 24-hour psychiatric wards was introduced as an exception to the total ban on smoking in health care facilities and in other facilities where health services are provided (3).
    Present studies show that e-cigarettes are more effective for smoking cessation than NRT in participants in whom NRT had previously failed, possibly due to the experience of effects of vaping such as positive aspects of socialization, hand-mouth ritual, inhaling, flavor, immediate nicotine effects, encouragement to use e-cigarettes, or the lower costs of e-liquid (4). What's more, using e-cigarettes can even be considered a NRT (2). Heat-not-burn (HNB) tobacco products also have the potential to be a reduced risk product for public health compared to conventional cigarettes (5).
    Appreciating the effectiveness of smoking cessation methods in hospitalized patients described by Brown and Colleagues (1), it would be advisable to use all available methods of reducing smoking in psychiatric units, including harm reduction forms as e-cigarettes or/and HNB products. However, smoking e-cigarettes or HNB products requires appropriate and professional smoking rooms.

    1. Brown RA, Minami H, Hecht J, et al. Sustained Care Smoking Cessation Intervention for Individuals Hospitalized for Psychiatric Disorders: The Helping HAND 3 Randomized Clinical Trial. JAMA Psychiatry. Published online May 05, 2021. doi:10.1001/jamapsychiatry.2021.0707
    2. Prochaska JJ, Das S, Young-Wolff KC. Smoking, Mental Illness, and Public Health. Annu Rev Public Health. 2017;38:165-185. doi:10.1146/annurev-publhealth-031816-044618
    3. Service of the Republic of Poland, Patient Rights Ombudsman: Psychiatric hospital - technical conditions. Accessed May 6, 2021. https://www.gov.pl/web/rpp/szpital-psychiatryczny-uwarunkowania-techniczne
    4. Hajek P, Phillips-Waller A, Przulj D, et al. A Randomized Trial of E-Cigarettes versus Nicotine-Replacement Therapy. N Engl J Med. 2019;380(7):629-637. doi: 10.1056/NEJMoa1808779.
    5. World Health Organization: Heat-Not-Burn tobacco products information sheet. Accessed May 6, 2021. https://apps.who.int/tobacco/publications/prod_regulation/heat-not-burn-products-information-sheet/en/index.html