Efficacy of Group Tobacco Cessation Behavioural Intervention Among Tobacco Users With Concomitant Mental Illness in Kenya

Abstract

Introduction: The prevalence of tobacco use among people with mental illness is nearly twice that of the general population. Psychotropic medications for tobacco cessation are relatively expensive for most Kenyans. Behavioural counselling and group therapy have been found to be effective, lower cost strategies to promote tobacco cessation, yet have not been studied in Kenya among individuals with concomitant mental illness. Objectives: Using a randomised clinical trial design, this study sought: 1) to determine the efficacy and safety of a group tobacco cessation behavioural intervention among tobacco using patients with mental illnesses on tobacco cessation at 24 weeks and 2) to evaluate the effect of a group tobacco cessation behavioural intervention on health-related quality of life of patients with mental illnesses at 24 weeks. Methods: Tobacco users with mental illness who were part of an outpatient mental health program at the Mathari Referral and Teaching Hospital’s Clinic for Substance Abuse Treatment (CSAT) and outpatient clinics in Nairobi, Kenya were recruited and allocated into intervention and control groups (1:1). Participants allocated to the intervention group were invited to participate in 1 of 5 tobacco cessation groups. The intervention group received brief counselling based on the 5As (i.e. Ask, Advise, Assess, Assist and Arrange) and assigned to a tobacco cessation group behavioural intervention for 3 months (Meeting fortnightly), which included strategies to manage cravings and withdrawal; stress, anxiety, and coping with depression; assertiveness training and anger management; reasons to quit; benefits of quitting; and different ways of quitting. The intervention group was followed up for 3 months (meeting monthly) after completion of the intervention. Individuals allocated to the control group received usual care. The primary outcome was tobacco cessation at 24 weeks, which was measured through salivary cotinine strips. Secondary outcomes included reduction in tobacco amount used and health-related quality of life at 24 weeks. Between-group event rates of tobacco use were compared between the two groups by unadjusted and adjusted Cox proportional hazard models to evaluate the effect of the intervention on the study outcomes, while differences in HRQoL scores xiii were analysed using paired t-test. Within-trial qualitative data were also collected using focused group discussions with trial participants to understand their barriers to successful cessation and subsequent facilitators. Data were thematically analyzed. Results: Participants’ mean age was 35 (SD=9) years, 87% were male, and 42% had completed secondary education. More than half (65%) had substance use disorders (diagnosed), and 15% had major depressive disorder. Almost all participants (94%) used cigarettes at baseline, and participants smoked for a mean of 13 (SD=11) years and a mean of 14 (SD=7) sticks daily. Three-quarters of participants reported using other substances (substance use- not diagnosed). Participants allocated to the intervention group reported a higher cessation rate (15.2% vs 0% at week 12; P=0.02 and 9.1% versus 0%; P=0.10) at week 24, and lower number of sticks smoked (97% vs 58.6%, P<0.0001) compared with control group participants at 24-week follow-up. The unadjusted results showed that participants in the intervention group were almost 14 times more likely to reduce smoking than participants in the control group (97.0% in intervention group vs 58.6% in control group, HR 13.85 [95% CI, 3.95-48.59]). Intervention group participants reported higher health-related quality of life scores in all domains at the end of the study compared with control group participants, including: physical domain (30.6% vs 10.4% OR=3.79 [95% CI, 1.25-11.48]), psychological domain (28.6% vs 16.7% OR=2.19 [95% CI, 0.75-5.33]), social relationships (30.6% vs 16.7% OR=2.21 [95%, 0.83-5.83]), and environmental domain (34.7% vs 8.3% OR=5.84 [95%, 1.79-19.03]). Qualitative results identified themes under barriers to quitting tobacco use including: peer influence, withdrawal symptoms, fear of complete cessation, other substance use, and end-month disputes. Themes that were facilitators employed by participants to supplement their cessation attempts included: oral stimulation and spousal and friend support. Conclusion: This group tobacco cessation behavioural intervention among persons with mental illness successfully identified an effective, accessible intervention that improves quality of life in this high-burden outpatient population in Kenya. Future research is needed to evaluate the effectiveness of implementation of this intervention in larger and more diverse populations.