To The Editor: We would like to contribute comments on the article “A Randomized Controlled Trial of a Smoking Cessation Intervention Among People With a Psychotic Disorder” (1) by Amanda Baker, Ph.D., and colleagues. First, the authors conclude that therapy procedures designed to enhance completion of smoking cessation intervention may enhance cessation rates in future studies. It is obvious that they seemingly attribute a higher smoking cessation or reduction to a dose-response effect of motivational interviewing and cognitive behavior therapy (CBT). However, some studies have shown that stage of change (2) is associated with compliance to the treatment program or clinical trial as well as final outcomes (3). Readiness to quit seems to play a key role in the prediction of smoking cessation or reduction, which is also evidenced in the article by Dr. Baker and colleagues, since they mention the extent of the stage of change in the pretrial and postbaseline periods. Indeed, the condition of compliance to a treatment program can be only considered as an intermediate outcome between readiness to quit and final smoking outcomes. It is also in accordance with the findings of our study, which is a randomized controlled trial of smoking reduction in inpatients with chronic schizophrenia. The patients with a strong readiness to quit (preparator or contemplators) were 7.7 times (p=0.003) more likely to reduce smoking than those with a weak readiness to quit (precontemplators), with adjustments for covariates including severity of tobacco dependence, antipsychotics, and clinical symptoms. We conjecture that pretrial scores of the stage of change in the three treatment groups in the article by Dr. Baker and colleagues may be proportional to subsequent compliance to CBT sessions. Second, we would like to compare the preliminary data of our research with their article. In our study, 110 male participants (schizophrenia: 77.3%; schizoaffective disorder: 22.7%) who smoked an average of 16 cigarettes per day were recruited. The 7-day point prevalence of abstinence at 8 weeks postbaseline of our study was 0.9% versus 15%, and the percentage of smoking reduction larger than 50% was 11.8% versus 43.5%. Possible explanations for the discrepancies between our study and the study conducted by Dr. Baker and colleagues, respectively, could be the distribution of age (42 years versus 37 years), sex (male only versus both sexes), ethnicity (Chinese versus Caucasian), schizophrenia diagnosis (100% versus 54%), stage of change (mostly precontemplation versus mostly preparation), and different adjunctive interventions (brief psychoeducation versus CBT and motivational interviewing). The article by Dr. Baker and colleagues has shown that smoking reduction may be a reasonable outcome measurement among people with psychosis. In addition, we would like to emphasize that motivation may play an important role in predicting the success of smoking cessation.
1.Baker A, Richmond R, Haile M, Lewin TJ, Carr VJ, Taylor RL, Jansons S, Wilhelm K: A randomized controlled trial of a smoking cessation intervention among people with a psychotic disorder. Am J Psychiatry 2006; 163:1934–19422.DiClemente CC, Prochaska JO, Fairhurst SK, Velicer WF, Velasquez MM, Rossi JS: The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psychol 1991; 59:295–3043.Dino G, Kamal K, Horn K, Kalsekar I, Fernandes A: Stage of change and smoking cessation outcomes among adolescents. Addict Behav 2004; 29:935–940
The authors report no competing interests.