Smoking cessation is possible for individuals with schizophrenia but the relapse rate is high. It is necessary to develop more flexible approaches to help these patients. The aim of this study was to examine the feasibility of an intervention approach that integrates counseling and exercise for participants with schizophrenia or schizoaffective disorder. A single group prospective design was used in this study. A sample of inpatients with schizophrenia or schizoaffective disorder participated in a program called “oxygen group”, a program combining five sessions of smoking reduction counseling and three sessions of moderate intensity exercise over an 8-week period. Tobacco consumption, motivation, carbon monoxide level, anxiety and depression, smoking self-efficacy, nicotine dependence and waist circumference were measured pre- and post-intervention. Participants reported their satisfaction with the study characteristics after completion of the intervention. Smoking consumption and CO level were assessed at 6-week post-intervention follow-up. Twelve individuals (mean age 45.7±10.8 years) were recruited. Participant attendance was 81.3%. There were no dropouts. Significant decreases were found for tobacco consumption (P=.04) and CO rate (P=.003) at the end of the intervention and were maintained at 6-week follow-up. Compared to baseline levels, there were no changes in depression and anxiety. Smoking cessation motivation increased significantly. This intervention appears feasible and acceptable to patients with schizophrenia and there were promising findings regarding smoking reduction. Larger trials to test the intervention are warranted.
SCHIZOPHRENIA IS ASSOCIATED with a higher rate of physical illness and there is a 2.5 to 3 times higher mortality risk compared to those observed in the general population (
Saha et al., 2007
). The main death causes of individuals with schizophrenia are cardiac disorders (29%), cancer (including lung cancer) (19%), and pulmonary diseases (17%) (Capasso et al., 2008
). Smoking is an avoidable behavior that increases the risk of premature mortality. Smoking prevalence is particularly higher for individuals with psychiatric disorders (Ziedonis et al., 2008
). Indeed, a meta-analysis reported an odds ratio of smoking prevalence of 5.9 (95%CI 4.9–5.7) for individuals with schizophrenia compared to the general population (de Leon and Diaz, 2005
). Fifty percent of individuals with schizophrenia are heavy smokers (>25 cigarettes per day) (Winterer, 2010
). Studies of smoking topography found more puffs per cigarette and greater carbon monoxide boost, in smokers with schizophrenia compared to controls (Tidey et al., 2005b
). Cigarette smoking is also associated with other unhealthy lifestyle behavior (alcohol consumption, drug use, unhealthy food, and physical inactivity) and poorer quality of life for this specific population (Kilian et al., 2006
).There is growing evidence showing that smoking reduction increases the probability of future cessation among samples without psychiatric disorders (
Asfar et al., 2011
, Hughes and Carpenter, 2006
). For smokers with psychiatric disorders, Hitsman et al., 2009
suggest to include smoking reduction as an initial goal for improving treatment efficacy. For individuals with schizophrenia, three different areas may reduce smoking behavior: limiting access to cigarettes, use of nicotine-replacement therapy (NRT) drug and behavior change (McChargue et al., 2002
). In this context, the “oxygen group” (OG) intervention endeavours to initiate a behavior change based on counseling and exercise.Smoking reduction counseling aims to develop the following skills: to increase the amount of time between each smoked cigarette, to eliminate cigarettes associated with particular locations or times of the day, and to manage social pressures and external temptations (
Riggs et al., 2001
). However, it may be that individuals with schizophrenia who are trying to abstain from smoking are particularly sensitive to negative effect and withdrawal symptoms—which in turn are associated with relapse. For example, a brief abstinence (2 hours) increased urge levels, nicotine withdrawal symptom levels, and negative effect for smokers with schizophrenia (Tidey et al., 2005a
). The level of tobacco craving is significantly greater 15 minutes post-smoking in people with schizophrenia compare to controls, despite similar scores in dependence (Lo et al., 2011
). Accordingly, it may be important to teach self-help strategies that can alleviate cravings and withdrawal symptoms during smoking reduction attempts. Exercise could be considered as such a strategy. A systematic review reported that one session of aerobic or isometric exercise or walking reduces the intensity of craving, withdrawal symptoms and negative affect during temporary smoking abstinence among smokers without psychiatric disorders (Taylor et al., 2007
). These results have not been verified in a sample of patients with schizophrenia (Arbour-Nicitopoulos et al., 2011
). Nevertheless, Vancampfort et al., 2010
reported that one 20 minute session of aerobic exercise decreased state anxiety and psychological stress and increased well-being in individuals with schizoaffective disorder.- Vancampfort D.
- De Hert M.
- Knapen J.
- Wampers M.
- Demunter H.
- Deckx S.
- Maurissen K.
- et al.
State anxiety, psychological stress and positive well-being responses to yoga and aerobic exercise in people with schizophrenia: A pilot study.
Disability and Rehabilitation. 2010; https://doi.org/10.3109/09638288.2010.509458
Therefore, the present study aimed to evaluate the feasibility, acceptability and effects of the OG intervention (smoking reduction counseling and exercise) on smoking consumption. We hypothesized first, that recruiting patients to such counseling and exercise was feasible; second, that the participants would decrease tobacco consumption at the end of the intervention compared to baseline.
Method
A single group prospective study design was used with assessments at baseline, at end of intervention and 6 weeks follow-up.
Participants
Over a 1-month period, all inpatients who smoked and had a DSM-IV-TR (
American Psychiatric Association, 2000
) diagnosis of schizophrenia or schizoaffective disorder within one psychiatric clinic were invited to participate. To be included in the study, subjects had to: (1) be diagnosed with schizophrenia or schizoaffective disorders (the diagnosis was established by experienced psychiatrists responsible for the patients' treatment); (2) be aged ≥18 years; (3) smoke at least 15 cigarettes per day for at least 1 year, (4) be able to take part in a group, and (5) speak French. Exclusion criteria included diagnosis of substance dependence, intellectual disability, uncontrolled hypertension, peripheral vascular disease, or severe chronic obstructive pulmonary diseases and use of NRT. Informed consent was obtained. Participants did not get any type of compensation to participate in the study.Measurements
Characteristics
Sociodemographic characteristics measured at baseline included age, gender, body mass index (BMI) and waist circumference (WC). BMI was calculated as weight (kg) divided by height (m2). Waist circumference (rounded to the nearest half centimeter) was measured at the midpoint between the lower border of the rib cage and the iliac crest. Smoking variables assessed at baseline included age at smoking initiation, age at daily smoking, history of dependence, number of quit attempts, number of cigarettes smoked during the last 7 days and expired air CO concentration (Bedfont Smokerlyzer).
Smoking Behavior
Smoking behavior was evaluated pre- and post-intervention. Severity of nicotine dependence was assessed by the Fagerström Test for Nicotine Dependence (FTND) (
Japuntich et al., 2009
). Smoking self-efficacy was evaluated by the Smoking Self-Efficacy Questionnaire (SEQ-12). The 12 items measured confidence in ability to refrain from smoking when facing internal and external stimuli (Etter et al., 2000
). The Smoking cessation motivation questionnaire (Q-MAT) including four questions with a maximum score of 20 was administered as well (Aubin et al., 2004
). To evaluate whether the participants were in the process of decreasing cigarette consumption or intend to do so, the distribution across the transtheoretical model (TTM) stages of change was assessed by an algorithm including five questions with a yes/no response format. These questions correspond to the five stages of change i.e. precontemplation, contemplation, preparation, action and maintenance and were adapted from a smoking reduction study (Meyer et al., 2004
).Depression and Anxiety
Mood disorders were assessed by the Hospital Anxiety and Depression Scale Depression (HADS) (pre- and post-intervention). This scale includes fourteen items, seven related to anxiety and seven related to depression, each item score ranged from 0 and 3 (
Allan and Martin, 2009
, - Allan R.
- Martin C.R.
Can the hospital anxiety and depression scale be used in patients with schizophrenia?.
Journal of Evaluation in Clinical Practice. 2009; 15: 134-141https://doi.org/10.1111/j.1365-2753.2008.00968.x
Razavi et al., 1989
, Zigmond and Snaith, 1983
).Adherence and Safety
Adherence to OG intervention was assessed by recording attendance to exercise and counseling sessions. Dropouts were defined as participants who missed more than 50% of the sessions. The intervention was considered safe if levels of depression and anxiety, waist circumference and BMI were not significantly increased at the end of intervention.
Smoking Reduction
Smoking reduction was assessed by the number of cigarettes smoked within the last 7 days and the expired air CO concentration pre-, post-intervention and at 6 weeks follow-up.
Feedback Questionnaire
A feedback questionnaire was administered to participants to collect their impressions through three open questions: 1—Is there anything else you want to tell us about your experiences?, 2—What did you like about the OG program?, 3—Could you propose any improvements for OG intervention?
Intervention
Two trained therapists (a psychiatric nurse and an exercise specialist) delivered the OG intervention according to a guideline. Group size did not exceed 6 patients. The OG followed an 8-week counseling and exercise intervention that consisted of five 75 min “smoking reduction” group sessions and three 90 min exercise sessions. Length of OG intervention was based on those observed in previous studies on smoking reduction or heart disease risk reduction involving individuals with schizophrenia (
Given at the end of session.
Baker et al., 2009
, - Baker A.
- Richmond R.
- Castle D.
- Kulkarni J.
- Kay-Lambkin F.
- Sakrouge R.
- Filia S.
- et al.
Coronary heart disease risk reduction intervention among overweight smokers with a psychotic disorder: Pilot trial.
The Australian and New Zealand Journal of Psychiatry. 2009; 43: 129-135https://doi.org/10.1080/00048670802607147
Baker et al., 2006
). The counseling intervention was based on the Prochaska Transtheoretical Model (TTM). The TTM is an integrative model of behaviour change (- Baker A.
- Richmond R.
- Haile M.
- Lewin T.J.
- Carr V.J.
- Taylor R.L.
- Jansons S.
- et al.
A randomized controlled trial of a smoking cessation intervention among people with a psychotic disorder.
The American Journal of Psychiatry. 2006; 163: 1934-1942https://doi.org/10.1176/appi.ajp. 163.11.1934
Prochaska et al., 2009
). The counseling sessions were designed to increase interest in smoking reduction and confidence in the ability to change. The feasibility of counseling sessions for reducing substance abuse based on TTM model has been explored in individuals with schizophrenia (Carey et al., 2002
, Esterberg and Compton, 2005
). Moreover, this model has been used in harm reduction contexts (Bradley-Springer, 1996
, Meyer et al., 2004
). Emphasis was given to methods to strengthen the patients' self-efficacy to reduce smoking, to use processes of change (cognitive and behavioural), and to engage in decisional balance (Riemsma et al., 2003
, Schumann et al., 2005
). Table 1 gives an overview of each session's content.Table 1Summary of the Content of OG Intervention.
| S | Behavioral/cognitive strategies | Content | Homeworks/tools |
|---|---|---|---|
| 1 Coun | ▪ Information | ▪ Increasing knowledge of the benefits of reducing tobacco smoking | Self measure of tobacco consumption |
| ▪ Motivational readiness | ▪ Increasing awareness of the risk of smoking | ||
| 2 Walk | ▪ Self-monitoring | ▪ Self measure of exertion and breathlessness by VAS | – |
| ▪ Social support | ▪ Building of social relationships to foster increased physical activity | ||
| 3 Coun | ▪ Consciousness raising | ▪ Decisional balance | Card “relaxation technique” |
| ▪ Social liberation | ▪ Playing role game | ||
| ▪ Identifying solution for change behavior | ▪ Discussion of problem-solving approach to address behaviors | ||
| ▪ Counter-conditioning | ▪ Stress management | ||
| 4 Walk | ▪ Feedback | ▪ Explicit information provided to subjects about their behavior | – |
| ▪ Self-monitoring | ▪ Self measure of pleasure and breathlessness by VAS | ||
| 5 Coun | ▪ Self-reevaluation | ▪ Self measure attempts of smoking reduction | Card “Solutions for testing new behaviors” |
| ▪ Helping relations | ▪ Discussion of problem-solving approach to adopt new behaviors | ||
| ▪ Self-liberation | ▪ Identifying discrepancies between behavior and goals | ||
| ▪ Reinforcement management | ▪ Measure of CO level and feedback | ||
| 6 Walk | ▪ Social modeling | ▪ Opportunities to watch similar others exercise | – |
| ▪ Self-monitoring | ▪ Self measure of tiredness and breathlessness by VAS | ||
| 7 Coun | ▪ Helping relations | ▪ Exchange of experiences between two groups | – |
| ▪ Peer education | ▪ Identifying specific solutions | ||
| 8 Coun | ▪ Self-reevaluation | ▪ Discussing about prevention of consumption increasing and problem-solving future for risk situations | Card “Prevention of increase consumption” |
| ▪ Reinforcement and feedback | ▪ Identifying a realistic and measurable goal setting at long term |
Notes. S=session; Coun=counseling; Walk=walking; VAS=visual analogue scale; CO=carbon monoxide expired.
The goal of the exercise sessions was to help patients cope with withdrawal symptoms (negative affect, anxiety and craving). During the supervised exercise sessions, participants were asked to achieve a 10-minute active warm-up, 50 minutes of walking (moderate intensity), and a 10-minute cool-down. An adapted physical activity educator supervised the sessions and recorded perceived exertion level (see Table 1).
Data Analysis
Differences between pre-, post-intervention and follow-up scores were calculated with non-parametric Wilcoxon signed rank tests using a .05 significance level. Data analysis was performed using SPSS V16.
Results
Twenty-one individuals were invited to participate in the study. Seven patients presented at least one exclusion criteria and two patients were hospitalized before the start of the study. Finally, 12 participants were included in the study. According to the DSM-IV-TR (
American Psychiatric Association, 2000
), three patients were diagnosed with a schizoaffective disorder and nine with schizophrenia of whom three had comorbid mixed personality disorder. All of the inpatients were prescribed atypical antipsychotic medication and three participants took mood stabilizers. No participants had a change in medication. Mean age was 45.7 (±10.8) years, ranging from 26 to 59 years. Three patients reported high school education and two were female. Four patients were overweight (BMI≥25 kg/m2) and three were obese (BMI≥30 kg/m2). Mean age at smoking initiation was 17.5 years (±3.5), mean age at daily smoking was 21.3 (±6.8). Four subjects reported a quit attempt in the previous year. The mean number of cigarettes within the last 7 days was 118 (±51.4) and four participants smoked hand rolled cigarettes. The individuals were classified in the precontemplation (3/12), contemplation (8/12) and preparation (1/12) stage for cutting down at baseline. Three subjects reported history of alcohol dependence and one had a history of marijuana dependence.Adherence and Safety
Participants attended an average of 81.3% of the total sessions scheduled in OG intervention (with three absences maximum); i.e. 6.5 (±1.2) sessions including 4.1 (±0.9) counseling and 2.3 (±0.7) exercise sessions. According to our criteria, no drop-out was recorded. Table 2 summarizes data regarding the OG safety.
P<.05
Table 2Safety and Effects Outcomes at Pre (t0), Post Intervention (t+8), and 6 Weeks Follow-up (t+14), (N=12).
| t0 | t+8 | t+14 | |
|---|---|---|---|
| HADS D-sub | 9.33 (4.0) | 7.83 (3.4) | – |
| HADS A-sub | 11.58 (2.2) | 11.08 (4.5) | – |
| BMI | 26.53 (3.5) | 26.55 (3.3) | – |
| WC | 95.8 (8.6) | 97 (7.0) | – |
| Q-MAT | 9.42 (1.7) | 12.5 (4.0) | – |
| FNTD | 5.33 (2.1) | 4.0 (2.1) | – |
| SEQ 12 | 27.25(18.5) | 23.50 (13.2) | – |
| Stage | |||
| Precontemplation | 3 | 2 | – |
| Contemplation | 8 | 2 | – |
| Preparation | 1 | 3 | – |
| Action | – | 5 | – |
| 7 day consumption | 118.25 (51.4) | 84.75 (58.0) | 96.10 (59.9) |
| CO | 30.91 (13.3) | 20.1 (7.8) | 24.50 (17.8) |
Notes. Means and standard deviations in parentheses. HADS D-sub=Hospital Anxiety and Depression Scale Depression—depression subcale; HADS A-sub=Hospital Anxiety and Depression Scale Depression—anxiety subcale; BMI=body mass index; WC=waist circumference; Q-MAT=Smoking cessation Motivation Questionnaire; FNTD=Fagerström Test for Nicotine Dependence; SEQ 12=Smoking Self-Efficacy Questionnaire; CO=carbon monoxide expired.
Smoking Reduction
Although this study was not adequately powered to detect significant differences, there were significant reductions in tobacco consumption and CO level expired compared to baseline. Indeed, using the past 7-day recall, five patients reduced by 50% or greater the number of cigarettes smoked post-intervention. Table 2 provides a summary of the data on the measures assessing the effects of OG intervention. Notably, there was a significant increase in smoking cessation motivation as measured by the Q-MAT.
Acceptability
Overall, comments recorded by the feedback questionnaire were positive in describing perceived benefits of participating in the intervention—“Walking and group sessions have helped me in staying positive and increasing my self confidence.” All individuals were interested in receiving specific advice from health professionals regarding reduction strategies as well as to facilitate exchanges with partner: “Training partner for support is an advantage for coming in session.” Participants noted that they would be interested in receiving information about nicotine replacement therapy and having more frequent walk sessions.
Discussion
The primary aim of our study was to investigate the safety and the feasibility of OG intervention in individuals with schizophrenia. The intervention adherence rate reached 83.1%, which is close to that observed in other studies that have described participation in an exercise intervention (72.4%) (
Marzolini et al., 2009
) or multibehavior intervention (80%) (McKibbin et al., 2006
) for patients with schizophrenia. Participant's comments related positive impacts of exercise sessions regarding the three following characteristics: walking, group and supervised session. These declarations confirmed the beneficial effects of OG intervention on physical activity barriers for schizophrenia patients (Johnstone et al., 2009
). However, more specific a motivational approach can be developed based on walk, address sensations, learn about exercise, cue exercise behavior (i.e. program based upon self efficacy theory) (Beebe and Smith, 2010
).These results support the acceptability of an OG intervention.Smoking reduction has been associated with weight gain (
Perkins et al., 1987
) and the emergence of depressive disorders in high dependence smokers (French Office of Smoking Prevention and FOSP, 2009
). In our pilot study, there were no increases in depression, anxiety, WC or BMI observed between baseline and post-intervention. One explanation could be related to the walking activity. Walking interventions have showed a decrease of body fat and level of depression in patients with schizophrenia or schizoaffective disorder (Acil et al., 2008
, Methapatara and Srisurapanont, 2011
). - Methapatara W.
- Srisurapanont M.
Pedometer walking plus motivational interviewing program for Thai schizophrenic patients with obesity or overweight: A 12 week, randomized, controlled trial.
Psychiatry and Clinical Neurosciences. 2011; 65: 374-380https://doi.org/10.1111/j.1440-1819.2011.02225.x
Taylor et al., 2006
reported that short sessions of walking improved mood during the abstinence time. The OG intervention did not involve any complications or adverse effects from the structured exercise or counseling program (injury, agitation, feeling bad, persecutory ideation, hallucinations). Therefore, OG intervention appears to be safe for patients with schizophrenia.Compared to baseline, a significant increase in smoking cessation motivation was observed post intervention, suggesting that this program could increase the probability of future cessation for these patients (
Hughes and Carpenter, 2006
). A stage progression for smoking reduction was observed for the majority of individuals. This observation might be explained by the development of new skills based on the processes of change used in the counseling sessions. Prochaska et al., 1992
suggest that the patients apply cognitive processes to progress through early stages, while behavioural processes are used to move toward maintenance stage.Compared to baseline, a significant decrease in cigarette consumption and CO level was observed at the end of intervention and 6 weeks after the program which suggests the absence of compensatory smoking (
Scherer, 1999
). In addition, five patients had reduced by 50% or more their cigarette consumption at the end of the intervention. A decrease of daily cigarettes of at least 50% is associated with an improvement of cardiovascular biomarkers (cholesterol concentrations, blood pressure, heart rate) and quality of life both in the short and long term in smokers without psychiatric disorders (Bolliger et al., 2002
, Hatsukami et al., 2005
). However, the level of tobacco dependence measured by FTND was unchanged. Two explanations can be suggested. First, the reduction of consumption was induced by changes in habits yet physiological dependence remained high. Second, the FTND scale is not appropriate for patients with schizophrenia (Steinberg et al., 2005
). Increased self-efficacy to refrain from smoking when facing internal and external stimuli was not observed in our study sample. The OG intervention has already been reported to not enhance enough smoking reduction expectations and in particularly positive and social expectations (Tidey and Rohsenow, 2009
).Three studies examined other smoking reduction approaches based exclusively on behavior change in patients with schizophrenia. Studies that used the 5 A's approach obtained modest effects at short and long term (
Dixon et al., 2009
, Steinberg et al., 2004
). Contingent monetary reinforcement had significant effects at very short term (5 days) (- Steinberg M.L.
- Ziedonis D.M.
- Krejci J.A.
- Brandon T.H.
Motivational interviewing with personalized feedback: A brief intervention for motivating smokers with schizophrenia to seek treatment for tobacco dependence.
Journal of Consulting and Clinical Psychology. 2004; 72: 723-728https://doi.org/10.1037/0022-006X.72.4.723
Tidey et al., 2002
).On the other hand, two studies have examined smoking reduction approaches based on behavior change in combination with NRT. These interventions (counseling phone calls+NRT; motivational interviewing/cognitive behavior therapy+NRT) had significant results at 6- and 12-months (
Baker et al., 2006
, - Baker A.
- Richmond R.
- Haile M.
- Lewin T.J.
- Carr V.J.
- Taylor R.L.
- Jansons S.
- et al.
A randomized controlled trial of a smoking cessation intervention among people with a psychotic disorder.
The American Journal of Psychiatry. 2006; 163: 1934-1942https://doi.org/10.1176/appi.ajp. 163.11.1934
Morris et al., 2011
). According to these findings, a randomized controlled trial (RCT) designed to compare the effect of counseling+exercise versus counseling+NRT on smoking reduction in individuals with schizophrenia could be interesting.- Morris C.D.
- Waxmonsky J.A.
- May M.G.
- Tinkelman D.G.
- Dickinson M.
- Giese A.A.
Smoking reduction for persons with mental illnesses: 6-Month results from community-based interventions.
Community Mental Health Journal. 2011; https://doi.org/10.1007/s10597-011-9411-z
Mental health nurses can develop new strategies for changing health behaviors in patients with schizophrenia through holistic approaches (
Vreeland, 2007
). Counseling and physical activity seem to be a promising component of holistic approaches for patients in psychiatric care (Happell et al., 2011
). The Solution Focuses Model offers an approach to engage patients in smoking reduction and active lifestyle in current practice (i.e. three phases: developing skills and resources, extending opportunity for patient to practice these new skills and develop further support social) (- Happell B.
- Platania‐Phung C.
- Scott D.
Placing physical activity in mental health care: A leadership role for mental health nurses.
International Journal of Mental Health Nursing. 2011; 20: 310-318https://doi.org/10.1111/j.1447-0349.2010.00732.x
McAllister, 2010
, McAllister et al., 2006
).Limitations
While this study provides preliminary evidence about the feasibility of counseling and exercise to reduce smoking in individuals with schizophrenia, the results must be interpreted with caution. Indeed, small study sample and lack of control condition limit generalization of results. A Hawthorne effect may have occurred due to awareness of participation in the study. Therefore the intervention should be replicated using a larger sample randomized controlled design. Finally, only the stage concept of TTM has been evaluated whereas other concepts such as processes of change, decisional balance, and temptations were not measured.
Conclusion
The OG intervention was feasible for individuals with schizophrenia and promising results were found. Mental health nurses represent the ideal candidates for assessing smoking reduction motivation and promoting physical activity in this population. A future pilot study based on recommendations of Medical Research Council (
Craig et al., 2008
), could provide more information about effect sizes, long term effects and cost effectiveness. Smoking cessation rate after the OG program should be examined in future trials. The OG intervention could be a preliminary intervention to increase smoking cessation motivation and develop news skills and behaviors before the initiation of smoking cessation based on counseling, aerobic exercise and nicotine replacement therapy.Acknowledgment
We would like to thank Johan Vidal, Guillaume Perez, Paul Lacaze, Dorothée Becq, Marie Christine Noah, Catherine Djanian, Adrian Taylor and Xavier Quantin.
Funding: None of the funding sources was involved at any stage.
References
- The effects of physical exercises to mental state and quality of life in patients with schizophrenia.Journal of Psychiatric and Mental Health Nursing. 2008; 15: 808-815
- Can the hospital anxiety and depression scale be used in patients with schizophrenia?.Journal of Evaluation in Clinical Practice. 2009; 15: 134-141https://doi.org/10.1111/j.1365-2753.2008.00968.x
- Diagnostic and statistical manual of mental disorders: DSM-IV-TR. American Psychiatric Publication, 2000
- Smoking cessation in women with severe mental illness: exploring the role of exercise as an adjunct treatment.Archives of psychiatric nursing. 2011; 25: 43-52https://doi.org/10.1016/j.apnu.2010.05.006
- Do smoking reduction interventions promote cessation in smokers not ready to quit?.Addictive Behaviors. 2011; 36: 764-768https://doi.org/10.1016/j.addbeh.2011.02.003
- Smoking cessation motivation questionnaire (Q-MAT): Construction and validation.Alcoologie et addictologie. 2004; 27: 19-25
- Coronary heart disease risk reduction intervention among overweight smokers with a psychotic disorder: Pilot trial.The Australian and New Zealand Journal of Psychiatry. 2009; 43: 129-135https://doi.org/10.1080/00048670802607147
- A randomized controlled trial of a smoking cessation intervention among people with a psychotic disorder.The American Journal of Psychiatry. 2006; 163: 1934-1942https://doi.org/10.1176/appi.ajp. 163.11.1934
- Feasibility of the Walk, Address, Learn and Cue (WALC) intervention for schizophrenia spectrum disorders.Archives of Psychiatric Nursing. 2010; 24: 54-62
- Influence of long-term smoking reduction on health risk markers and quality of life.Nicotine & Tobacco Research. 2002; 4: 433-439https://doi.org/10.1080/1462220021000018380
- Patient education for behavior change: Help from the transtheoretical and harm reduction models.The Journal of the Association of Nurses in AIDS Care: JANAC. 1996; 7: 23-33
- Mortality in schizophrenia and schizoaffective disorder: An Olmsted County, Minnesota cohort: 1950–2005.Schizophrenia Research. 2008; 98: 287-294https://doi.org/10.1016/j.schres.2007.10.005
- The feasibility of enhancing psychiatric outpatients' readiness to change their substance use.Psychiatric Services. 2002; 53: 602-608
- Developing and evaluating complex interventions: The new Medical Research Council guidance.BMJ. 2008; 337: a1655https://doi.org/10.1136/bmj.a1655
- A meta-analysis of worldwide studies demonstrates an association between schizophrenia and tobacco smoking behaviors.Schizophrenia Research. 2005; 76: 135-157
- Is implementation of the 5 A's of smoking cessation at community mental health centers effective for reduction of smoking by patients with serious mental illness?.The American Journal on Addictions. 2009; 18: 386-392https://doi.org/10.3109/10550490903077747
- Development and validation of a scale measuring self-efficacy of current and former smokers.Addiction. 2000; 95: 901-913
- Smoking behavior in persons with a schizophrenia-spectrum disorder: A qualitative investigation of the transtheoretical model.Social Science & Medicine. 2005; 61: 293-303
French Office of Smoking Prevention, FOSP. (2009). Recommandations: Smoking cessation for patients with psychiatric disorders. (p. 1–8). Paris.
- Placing physical activity in mental health care: A leadership role for mental health nurses.International Journal of Mental Health Nursing. 2011; 20: 310-318https://doi.org/10.1111/j.1447-0349.2010.00732.x
- Effects of cigarette reduction on cardiovascular risk factors and subjective measures.Chest. 2005; 128: 2528-2537https://doi.org/10.1378/chest.128.4.2528
- Treatment of tobacco dependence in mental health and addictive disorders.Canadian Journal of Psychiatry. 2009; 54: 368-378
- Does smoking reduction increase future cessation and decrease disease risk? A qualitative review.Nicotine & Tobacco Research. 2006; 8: 739-749https://doi.org/10.1080/14622200600789726
- Do smokers know what we're talking about? The construct validity of nicotine dependence questionnaire measures.Psychological Assessment. 2009; 21: 595-607https://doi.org/10.1037/a0017312
- Barriers to uptake of physical activity in community-based patients with schizophrenia.Journal of Mental Health. 2009; 18: 523-532https://doi.org/10.3109/09638230903111114
- Health behavior in psychiatric in-patients compared with a German general population sample.Acta Psychiatrica Scandinavica. 2006; 114: 242-248https://doi.org/10.1111/j.1600-0447.2006.00850.x
- Tobacco craving in smokers with and without schizophrenia.Schizophrenia Research. 2011; 127: 241-245https://doi.org/10.1016/j.schres.2010.06.017
- Feasibility and effects of a group-based resistance and aerobic exercise program for individuals with severe schizophrenia: A multidisciplinary approach.Mental Health and Physical Activity. 2009; 2: 29-36
- Would smokers with schizophrenia benefit from a more flexible approach to smoking treatment?.Addiction. 2002; 97: 785-793
- A lifestyle intervention for older schizophrenia patients with diabetes mellitus: A randomized controlled trial.Schizophrenia Research. 2006; 86: 36-44
- Solution focused nursing: A fitting model for mental health nurses working in a public health paradigm.Contempory Nurse. 2010; 34: 149-157
- Solution focused nursing: An evaluation of current practice.Nurse Education Today. 2006; 26: 439-447
- Pedometer walking plus motivational interviewing program for Thai schizophrenic patients with obesity or overweight: A 12 week, randomized, controlled trial.Psychiatry and Clinical Neurosciences. 2011; 65: 374-380https://doi.org/10.1111/j.1440-1819.2011.02225.x
- Subtyping general population smokers not intending to quit by stages to reduce smoking.Nicotine & Tobacco Research. 2004; 6: 1043-1050
- Smoking reduction for persons with mental illnesses: 6-Month results from community-based interventions.Community Mental Health Journal. 2011; https://doi.org/10.1007/s10597-011-9411-z
- Weight gain associated with decreases in smoking rate and nicotine intake.The International Journal of the Addictions. 1987; 22: 575-581
- In search of how people change. Applications to addictive behaviors.The American Psychologist. 1992; 47: 1102-1114
- The transtheoretical model behavior change.in: The Handbook of Health Behavior Change. Third. Springer Publishing Company, 2009: 85-106
- Validation of the HADS French version in canceras hospitalized patients.Revue de Psychologie Appliquée. 1989; 39: 295-307
- Two behavioral treatments for smoking reduction: A pilot study.Nicotine & Tobacco Research. 2001; 3: 71-76https://doi.org/10.1080/14622200020032114
- Systematic review of the effectiveness of stage based interventions to promote smoking cessation.BMJ. 2003; 326: 1175-1177https://doi.org/10.1136/bmj.326.7400.1175
- A systematic review of mortality in schizophrenia: Is the differential mortality gap worsening over time?.Archives of General Psychiatry. 2007; 64: 1123-1131https://doi.org/10.1001/archpsyc.64.10.1123
- Smoking behaviour and compensation: A review of the literature.Psychopharmacology. 1999; 145: 1-20
- Stage of change transitions and processes of change, decisional balance, and self-efficacy in smokers: A transtheoretical model validation using longitudinal data.Psychology of Addictive Behaviors. 2005; 19: 3-9https://doi.org/10.1037/0893-164X.19.1.3
- Applicability of the Fagerström Test for Nicotine Dependence in smokers with schizophrenia.Addictive Behaviors. 2005; 30: 49-59
- Motivational interviewing with personalized feedback: A brief intervention for motivating smokers with schizophrenia to seek treatment for tobacco dependence.Journal of Consulting and Clinical Psychology. 2004; 72: 723-728https://doi.org/10.1037/0022-006X.72.4.723
- Effects of walking on cigarette cravings and affect in the context of Nesbitt's paradox and the circumplex model.Journal of Sport & Exercise Psychology. 2006; 28: 18-31
- The acute effects of exercise on cigarette cravings, withdrawal symptoms, affect and smoking behaviour: A systematic review.Addiction. 2007; 102: 534-543
- Smoking expectancies and intention to quit in smokers with schizophrenia, schizoaffective disorder and non-psychiatric controls.Schizophrenia Research. 2009; 115: 310-316https://doi.org/10.1016/j.schres.2009.09.032
- Cigarette smoking topography in smokers with schizophrenia and matched non-psychiatric controls.Drug and Alcohol Dependence. 2005; 80: 259-265https://doi.org/10.1016/j.drugalcdep.2005.04.002
- Subjective and physiological responses to smoking cues in smokers with schizophrenia.Nicotine & Tobacco Research. 2005; 7: 421-429https://doi.org/10.1080/14622200500125724
- Contingent monetary reinforcement of smoking reductions, with and without transdermal nicotine, in outpatients with schizophrenia.Experimental and Clinical Psychopharmacology. 2002; 10: 241-247
- State anxiety, psychological stress and positive well-being responses to yoga and aerobic exercise in people with schizophrenia: A pilot study.Disability and Rehabilitation. 2010; https://doi.org/10.3109/09638288.2010.509458
- Bridging the gap between mental and physical health: A multidisciplinary approach.The Journal of Clinical Psychiatry. 2007; 68: 26-33
- Why do patients with schizophrenia smoke?.Current Opinion in Psychiatry. 2010; 23: 112-119https://doi.org/10.1097/YCO.0b013e3283366643
- Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report.Nicotine & Tobacco Research. 2008; 10: 1691-1715
- The hospital anxiety and depression scale.Acta Psychiatrica Scandinavica. 1983; 67: 361-370
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Published online: December 26, 2012
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© 2013 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
