INTRODUCTION

The 19% of adults in the U.S. who have a mental illness are over-represented among smokers.¹ Although the general smoking prevalence is 14%,² smoking prevalence among those who have a mental health condition (MHC) is 2‒4 times this rate.³ The population with MHC faces high rates of morbidity and mortality related to tobacco-related illnesses,^4,5 and those who smoke have more psychiatric symptoms, have increased psychiatric and general hospitalizations, and require higher dosages of psychotropic medications than the nonsmoking population with MHC.6, 7, 8, 9, 10 The healthcare sector has been slow to promote cessation services for this at-risk population even though 75% of people with an MHC desire to quit, 65% made a quit attempt in the past year, and cessation treatments are well tolerated and effective.^8,11, 12, 13, 14 The population with MHC is able to quit smoking at significant rates when provided a treatment that meets the clinical guideline standard, including 3 or more counseling sessions and a full course of cessation pharmacotherapy.^7,15,16

Quitlines are a widely available, evidence-based, tobacco cessation service. Quitlines generally offer some combination of brief telephonic counseling combined with cessation pharmacotherapy as well as online and texting platforms. The efficacy of quitlines for the general population is widely acknowledged,16, 17, 18 but quitline vendors initially voiced concerns about serving people with MHCs, citing staff’s lack of training, potential liability issues, and time burden. Quitlines further questioned whether the MHC population would utilize telephonic services,¹⁹ but by 2009, quitlines were reporting that the prevalence of MHC among callers ranged from 19% to 50%.^8,20, 21, 22 An early study found that a quarter of callers reported current major depression alone.²³ An observational study of quitlines across 3 states found that 46% of respondents reported 1 or more MHCs, with the most common conditions being depression, anxiety, and bipolar disorder.²⁴ Another 6-state pilot program found that 58%‒73% of callers reported an MHC history.²⁵ In response, the North American Quitline Consortium endorsed questions screening for MHCs and how MHCs might impact the ability to quit.²⁶ At least 90% of state quitlines are now utilizing optional Minimum Data Set (MDS) questions, and among these states, an average of 46% of callers report an MHC (North American Quitline Consortium, unpublished data, 2019).

Several studies have found 7-day abstinence rates for people with MHCs to be equivalent to general callers at the end of treatment and follow-up.20, 21, 22^,24 For callers to California Smokers’ Helpline (N=844), those with depression attempted to quit smoking at the same rate as callers without depression (p=0.34), and approximately 1 in 5 remained abstinent after 2 months.²³ Abstinence rates at 7-month follow-up for an observational study of quitline callers from Maryland, Nebraska, and North Carolina (N=3,132) were significantly lower for callers with an MHC than for callers without an MHC (22.0% vs 31.0%, p<0.001).²⁴ Yet, another observational 6-state study (Idaho, Kentucky, Michigan, Montana, Ohio, and Pennsylvania; N=4,960) also found that abstinence rates for callers with an MHC were substantial but lower than abstinence rates for callers without an MHC at 3-month (31% vs 43%, p<0.001) and 6-month follow-up (29% vs 40%, p<0.001). Quit rates were lowest for the subset of callers reporting that their MHC would hinder a quit attempt at 3-month (23% vs 34%, p<0.001) and 6-month follow-up (24% vs 32%, p<0.001).²⁵

Questions remain regarding how quitlines might most effectively serve the population with MHC. All quitlines report that staff receive training to treat tobacco dependence in the population with MHC,²⁷ but the degree of training is variable.²⁸ There is expert consensus that smokers with MHCs often require more intense services, with longer duration of treatment, more frequent counseling, and higher doses and combinations of cessation medications.^3,16,24 Individuals with MHCs may also be more likely to quit when cognitive behavioral therapy, mood management skills, and motivational enhancement treatments are provided.29, 30, 31

This manuscript describes initial data for 2 large quitline vendors, Optum and National Jewish Health (NJH), which have initiated programming for the population with MHC. Optum is the quitline provider for 23 states and the District of Columbia; NJH is the quitline provider for 18 states. Feasibility, including available initial outcomes and participant characteristics, is described for these quitlines’ 2 unique protocols.