An Electronic Decision Support

System to Motivate People With Severe

Mental Illnesses to Quit Smoking
Mary F. Brunette, M.D.
Joelle C. Ferron, M.S.W., Ph.D.
Gregory J. McHugo, Ph.D.
Kristin E. Davis, Ph.D.
Timothy S. Devitt, Psy.D.
Sandra M. Wilkness, Ph.D.
Robert E. Drake, M.D., Ph.D.

Objective: Rates of cigarette smoking are high among people with se- nesses (schizophrenia and severe
vere mental illnesses compared with the general population (45%–90% mood disorders). These individuals
versus 20%). The authors developed a Web-based computer decision are more likely to start smoking and
support system that is tailored for use by people with cognitive deficits less likely to quit than those without
and is designed to stimulate motivation to quit smoking by using evi- mental illness (1,5,7,12).
dence-based treatment. Methods: This initial study used a quasi-experi- Smoking tobacco (even in small
mental design to test the decision support system among a convenience amounts) contributes to the develop-
sample of 41 smokers with severe mental illnesses. Researchers inter- ment of multiple diseases, including
viewed participants at baseline and two months later to assess for be- heart and lung diseases, stomach and
haviors indicative of motivation to quit smoking. A negative binomial re- pancreatic cancers, strokes, and dia-
gression modeled the outcome and controlled for baseline group dif- betes (13,14). Smoking is therefore
ferences. Results: Participants who used the decision support system considered the leading preventable
were significantly more likely to show any behavioral motivation to quit cause of death in the United States
smoking (such as meet with a clinician to discuss cessation, initiate ces- (11). Given the high rates of smoking,
sation treatment, or otherwise attempt to quit) (67% versus 35%; higher rates of these diseases are ex-
χ2=4.11, df=41, p=.04). Further, using the decision support system in- pected and have been found among
creased by a factor of 2.97, or about 300%, the expected number of ways people with severe mental illnesses
that a participant showed motivation. Conclusions: The encouraging re- (15). Recent reports have also shown
sults of this pilot study indicate that electronic decision supports may fa- a 25-year gap in the life expectancy of
cilitate motivation to quit smoking and use of cessation treatment this group compared with the general
among people with severe mental illnesses. (Psychiatric Services 62: population (16–19), which is largely
360–366, 2011) attributable to cardiovascular disease.
Quitting smoking reduces the risk
of death from tobacco-related disease:

R
ates of cigarette smoking are population (about 20%) (9) or among even a 60-year-old lifelong smoker
high among people with schiz- those with no history of mental illness gains three years of life expectancy by
ophrenia (45.3%–88.0%) (1– (about 12%) (8). Although rates of quitting, and those who quit before
6), bipolar disorder (58.1%–90.0%) smoking have decreased over the past age 35 have the same life expectancy
(4–8), and major depressive disorder 20 years in the general population as nonsmokers (14). Quit attempts are
(36.6%–73.0%) (4–8) compared with (10,11), they have remained high common among people with severe
the rate of smoking in the general among people with severe mental ill- mental illnesses (20,21) but are typi-
cally unsuccessful if not accompanied
by cessation treatment (4).
Dr. Brunette, Dr. Ferron, Dr. McHugo, Dr. Wilkness, and Dr. Drake are affiliated with People with severe mental illnesses
the Department of Psychiatry, Dartmouth Psychiatric Research Center, State Office Park tolerate and respond well to smoking
South, 105 Pleasant St., Concord, NH 03301 (e-mail: mary.f.brunette@dartmouth.edu). cessation medications approved by
Dr. Davis and Dr. Devitt are with Thresholds, Chicago. Dr. Wilkness, formerly also at the U.S. Food and Drug Administra-
Thresholds, is now with the Office of U.S. Senator Jeff Bingaman, Washington, D.C. tion (22–27). As in the general popu-
360 PSYCHIATRIC SERVICES o ps.psychiatryonline.org o April 2011 Vol. 62 No. 4
lation (28–30), in the population with
severe mental illness the strongest
effects were achieved with a combi-
nation of medications and behavioral
counseling. Combined treatment led
to abstinence for approximately half
of the study participants in the gen-
eral population and for somewhat
lower percentages among persons
with severe mental illnesses. For ex-
ample, 36% of patients with schizo-
phrenia had continuous abstinence
after 12 weeks of treatment with
nicotine replacement, bupropion,
and group cognitive-behavioral ther-
apy (25), and 43% had two weeks of
continuous abstinence after 12 weeks
of varenicline treatment with group
cognitive-behavioral therapy (27).
On the basis of this research, com-
bined medication and behavioral
smoking cessation interventions have
been recommended for people with
severe mental illnesses stabilized on
psychotropic medication (31–33).
However, people with severe mental
illnesses frequently do not use evi-
denced-based cessation treatments
because of lack of interest (34,35) or
lack of access (36).
How can clinicians engage patients
in evidence-based smoking cessation
treatment? Motivational interviewing
(37,38) and education (38) have been
shown to increase motivation to seek
treatment for smoking cessation
among people with severe mental ill-
ness. However, training and using cli-
nicians to conduct such interventions
involves time and money. The field
needs cost-effective, easily imple-
mented methods to motivate this
population to participate in evidence-
based smoking cessation treatments.
Decision support systems have the
potential to meet this need (39).
They can educate, motivate, and en-
gage users into treatment by provid-
ing simple scientific information
about a medical problem (such as
quitting smoking), information about
treatment options, an individually
tailored presentation of the risks and
benefits of treatments, and personal
testimonies that describe what the
treatment is like and that inspire
hope and motivation. Moreover, de-
cision support systems often include
exercises that allow participants to
explore the advantages and disadvan-
PSYCHIATRIC SERVICES o ps.psychiatryonline.org o April 2011 Vol. 62 No. 4
tages of making a decision, such as
quitting smoking, and to use other
motivational exercises that increase
intention to change. Numerous con-
trolled trials support their efficacy
(40). One large study, conducted in
the general population of the Neth-
erlands, demonstrated that the use of
a decision support system for smok-
ing cessation enhanced knowledge
about cessation methods, improved
attitudes toward use of cessation
tools, and increased confidence about
quitting, and it was associated with
more quit attempts and abstinence at
a six-month follow-up (41).
Electronic decision support sys-
tems delivered via the Internet on
home, clinic, or library computers
could provide an inexpensive, system-
atic method to educate and motivate
smokers with severe mental illnesses.
This group is interested in using com-
puters to get health information (42),
but decision support systems current-
ly available on the Internet may be
too visually complex and mechanical-
ly challenging for them (43) because
of cognitive limitations (44) or mini-
mal computer experience (42). Our
research group recently developed a
simple electronic decision support
system for smoking cessation de-
signed for use by smokers with severe
mental illnesses (45). The purpose of
this study was to test the effectiveness
of the first version of this motivation-
al tool.
Methods
Overview
This study used a quasi-experimental
design to test an electronic decision
support system for smoking cessation.
In 2009, a convenience sample of 41
smokers with severe mental illnesses
was assessed at baseline and two
months later for smoking characteris-
tics and behavioral indicators of moti-
vation for smoking cessation. At base-
line, all participants received a pam-
phlet on smoking cessation and a re-
ferral to a smoking cessation coun-
selor, who helped participants consid-
er treatment options. The interven-
tion group used the electronic deci-
sion support system shortly after the
baseline interview, whereas the con-
trol group was able to use the system
after the follow-up interview. The
study was approved by the Dart-
mouth Committee for the Protection
of Human Subjects, and participants
gave written informed consent.
Participants
Through flyers and posters and via
clinicians’ communication with their
patients, we recruited English-speak-
ing adult smokers with severe mental
illnesses who were receiving sup-
ported housing and comprehensive
psychiatric services at two settings
within a large, urban, psychosocial
rehabilitation center. Potential par-
ticipants were told that the purposes
of the study were to learn about
smoking among people who have a
mental illness and to try out a com-
puter program about smoking. They
were also told that they did not have
to change their smoking habits in or-
der to be in the study. Of 48 individ-
uals who initially expressed interest,
43 (90%) agreed to participate. Rea-
sons for not participating included
inability to read at a fifth-grade level
(N=2, 4%), severe psychiatric symp-
toms (N=1, 2%), and lack of interest
or unstated reason (N=4, 8%). The
final study group therefore included
41 participants.
Intervention
The electronic decision support sys-
tem is a simple, interactive, Web-
based program that is tailored for use
by people with cognitive deficits and
little computer experience. Following
national guidelines for usability (46),
we incorporated the following fea-
tures into the program. An optional
tutorial on how to use a computer
mouse is available at the beginning
for those who have not used a com-
puter. The program provides a small
amount of information on each page.
The large-font text is written at a
fifth-grade reading level and format-
ted simply on a blank background.
Users move from page to page by
clicking on large, clearly labeled but-
tons. Information is presented in a
linear sequence of pages with a maxi-
mum of one additional layer of infor-
mation that can be accessed under
some pages. The linear design of this
version required all users to move
through the bulk of information and
exercises in the motivational sections,
361
whereas in the treatment section
users can choose whether to view de-
tailed treatment information after
viewing basic information about
treatment. All users in the interven-
tion group chose to view treatment
information.
The program was designed to stim-
ulate motivation to quit smoking with
use of evidence-based treatment.
Health behavior change theory in-
formed the content development
(47–50). By changing knowledge and
attitudes, the program attempted to
increase the user’s motivation to quit
smoking and to use cessation treat-
ment to do so. Specifically, the pro-
gram focused on the perceived risks
of smoking and the perceived bene-
fits of cessation treatment. A video-
recorded narrator, who identifies
himself as a former smoker with
mental illness, guides users through
the program and encourages them to
quit smoking. He speaks to users at
the beginning of the program and in
between each section to introduce
users to the purpose and tasks of
each section.
Initially, the program assesses a
user’s smoking by asking how much
the user smokes and how much he or
she spends on tobacco. The user
blows into a carbon monoxide meter,
which provides a measure of the
severity of nicotine dependence. The
program then provides the user feed-
back on these assessments. The pro-
gram also gives information about the
health risks of smoking by presenting
an illustration of a body upon which
users can click to get more informa-
tion. Users answer questions about
their personal views of the pros and
cons of smoking and create a summa-
ry in the form of a decision balance.
These types of interactive exercises
were designed to personalize the im-
pact of smoking, improve attitudes
about quitting, and increase self-effi-
cacy for seeking smoking cessation
treatment.
A two-minute video presents a vi-
gnette of one patient’s attempt to
quit by using a nicotine patch. The
vignette is designed to develop social
norms for smoking cessation treat-
ment and increase self-efficacy for
quitting with cessation treatments.
The program provides information
362
about evidence-based smoking cessa-
tion treatments that can be viewed if
the user clicks on a “view” button.
The cessation treatment information
was designed to prepare users for a
discussion with a clinician about
choosing a treatment. At the end of
the program, users can print out a
personal report that summarizes
their level of smoking, pros and cons
of smoking, and treatment interests.
This report also repeats the referral
to the smoking cessation specialist
(received by all participants after the
baseline interview), who was avail-
able to discuss treatment options. All
users printed their report. A sign-up
sheet for meeting with the smoking
cessation specialist was also pointed
out to all participants after using the
decision support system, and this was
the point at which users could choose
to make an appointment with the
specialist.
Measures
The main outcome of the study was
whether participants became moti-
vated to quit smoking. Behaviors in-
dicative of motivation were assessed
with the behavioral motivation index,
a checklist developed for this study
that assessed whether the participant
met with a smoking cessation special-
ist to discuss smoking cessation treat-
ments, met with a physician to discuss
smoking cessation treatments, at-
tended a cognitive-behavioral treat-
ment group for smoking cessation,
initiated a medication treatment for
smoking cessation, and initiated a
quit attempt without treatment. Re-
search staff verified self-report of the
first four indicators with administra-
tive and medical records.
Medical records also provided psy-
chiatric diagnoses and demographic
characteristics of the sample. Struc-
tured interviews provided their psy-
chiatric history and information
about past computer use. Patients’
responses to the five-item Fager-
ström Test for Nicotine Dependence
(51), questions about quantity and
frequency of smoking, and an item
from the Stage of Change Scale (52)
provided information about smoking
characteristics. Attitudes about smok-
ing were assessed with the Attitudes
Towards Smoking Scale, an 18-item
PSYCHIATRIC SERVICES o ps.psychiatryonline.org o April 2011 Vol. 62 No. 4
scale with three subscales (adverse
effects, psychoactive benefits, and
pleasure) (53). Previous test-retest
correlations have been high (above
.81), and the difference between the
advantages and disadvantages sub-
scale scores has been shown to pre-
dict smoking cessation (53).
Procedures
Research staff conducted structured
interviews at baseline and two
months later. At baseline, research
staff gave participants a pamphlet
that provided information about how
to quit smoking (54) and a referral to
a smoking cessation specialist, an ex-
perienced addiction counselor whose
name and number were on the pam-
phlet. Participants were told they
could make an appointment with this
specialist that day or later during the
two-month follow-up period. They
also were told that they could talk
with the specialist about treatment
options for smoking cessation. Pre-
scribers of cessation medication
were aware of the study and avail-
able to all participants at both sites,
but they did not have a list of study
participants. A cognitive-behavioral
smoking cessation treatment group
was available to all participants at
both sites.
Staff then invited participants from
one residential treatment setting
(N=21) to use the electronic decision
support system within two weeks; in-
dividuals from another residential
treatment setting (N=20) were invit-
ed to use it after a three-month delay
(this group served as the wait-list
control group). The second treat-
ment setting offered less intensive
treatment programming, although
the same usual care for smoking ces-
sation was available. All 21 partici-
pants in the intervention group used
the decision support system once
within two weeks; no further use was
allowed. Lack of contact between
study participants in the two groups
prevented any contagion between
the groups for the main outcome. In
other words, participants who used
the EDSS were unlikely to talk with
participants from the control group
and persuade them to use smoking
cessation treatment.
All participants used the program.
The specific characteristics of their
use and the usability testing of the
program among people with severe
mental illnesses before this study es-
tablished that the system was compre-
hensible, easy to use, and took 30–90
minutes for users to complete.
All study participants continued to
receive usual care, which involved
psychosocial and medication treat-
ments for mental illness as well as res-
idential, vocational, and other servic-
es. Available care for smoking cessa-
tion included meeting with a coun-
selor (smoking cessation specialist) or
a psychiatrist to discuss smoking ces-
sation, medication for smoking cessa-
tion (including nicotine replacement
therapy, bupropion, and varenicline),
and a weekly cognitive-behavioral
therapy group for smoking cessation.
All study participants had equal ac-
cess to these treatments.
Statistical analysis
We used Statistical Analysis Software
to conduct the analyses for this study.
Using chi square tests and Student’s t
tests, we evaluated between-group
(control and intervention) differ-
ences in baseline characteristics that
were expected to affect behavioral
motivation (past two-month behav-
ioral motivation, Fagerström Test for
Nicotine Dependence score, and a
difference score calculated from the
Attitudes Towards Smoking Scale).
We used the chi square test to com-
pare differences between the inter-
vention and control groups on the di-
chotomized version (zero versus any
behaviors) of the behavioral motiva-
tion index at baseline and again at fol-
low-up. We used the summed items
of the behavioral motivation index at
the two-month follow-up to examine
group differences in a regression
analysis in which we adjusted for
baseline differences. Because the be-
havioral motivation index indicated
extravariability (overdispersion), we
used a negative binomial regression,
which allows the variance to exceed
the mean, to model this outcome
while controlling for baseline group
differences (55,56). The beta coeffi-
cient for the difference between the
two groups was exponentiated in or-
der to interpret its magnitude as an
odds ratio (56).
Results
Study group
The study group consisted predomi-
nantly of middle-aged African Am-
ericans with long-term schizophre-
nia spectrum disorders (Table 1).
Compared with the control group,
the intervention group included a
lower proportion of individuals with
schizophrenia spectrum disorders
and a higher proportion of individu-
als with an alcohol or drug use disor-
der. The intervention group had a
significantly higher mean score on
the adverse subscale of the Attitudes
Towards Smoking Scale, indicating
that the intervention group ex-
pressed more concern than the con-
trol group about the negative effects
of smoking. With computers avail-
able in the residence for those in the
intervention group, more partici-
pants in that group indicated that
they had used a computer. Smoking
characteristics did not differ be-
tween groups.

Table 1
Baseline characteristics of participants with serious mental illnesses who used or did not use an electronic decision support
system about smoking

Intervention (N=21) Control (N=20)

Characteristic N % N % Test statistic df p

Age (M±SD) 47±9 48±11 t=–.6 39 .60

Gender (male) 14 67 13 65 χ2=.01 1 1.00
Race (African American) 20 95 17 83 χ2=1.00 1 .30
Diagnosis
Schizophrenia spectrum disorder 9 43 19 95 χ2=13.00 1 <.01
Alcohol use disorder 10 48 3 15 Fisher exact .05
Drug use disorder 16 76 9 45 χ2=5.00 1 .03
Lifetime hospitalizations (M±SD) 10±12 10±10 t=–.1 39 .90
Computer use (>5 times) 11 52 6 30 χ2=6.00 2 .04
Age first smoked (M±SD) 17±4 20±7 t=–1.0 32 .20
Fagerstrom Test for Nicotine
Dependence score (M±SD)a 5±2 5±2 t=–.10 39 .90
Cigarettes smoked per day (M±SD) 12±8 16±10 t=–1.0 35 .20
Quit attempts in lifetime (M±SD) 5±11 4±4 t=.6 25 .50
Recent quit attempt 6 29 10 50 χ2=.08 1 .80
High stage changeb 9 43 7 35 χ2=3.00 3 .30
Attitudes Towards Smoking
subscale score (M±SD)
Benefitsc 14±3 14±3 t=–.06 39 1.00
Pleasured 14±4 13±4 t=.90 39 .40
Adversec 43±5 38±8 t=3.0 31 .02
a Possible scores range from 0 to 10, with higher scores indicating higher dependence.
b As measured by the Stage of Change Scale
c Possible scores range from 4 to 20, with higher scores indicating higher perceived benefits (or perceived adverse effects) from smoking.
d Possible scores range from 10 to 50, with higher scores indicating higher perceived pleasure from smoking.

PSYCHIATRIC SERVICES o ps.psychiatryonline.org o April 2011 Vol. 62 No. 4 363

Table 2
Behaviors over two-month follow-up indicating motivation to quit smoking
among patients with a serious mental illness who used or did not use an
electronic decision support system on smokinga
Outcome
Met with specialist
Started smoking cessation medication
Attended group
Started smoking cessation medication
and attended group
Attempts to quit
With no treatment
With and without treatmentb
Any motivation behavior
Any provider consultation
a Numbers do not add up to total because participants may have engaged in more than one motiva-
tion behavior.
b Individuals attempted to quit at least twice—at least once without treatment and at least once with
treatment.
Baseline smoking cessation
motivation behaviors
In the two months before the base-
line assessment, six participants
(29%) in the intervention group and
ten participants (50%) in the control
group had tried to quit smoking, ei-
ther with treatment or on their own,
with some using multiple quit strate-
gies. This difference was not signifi-
cant, suggesting that the treatment
and control groups had similar levels
of motivation to quit smoking at base-
line. The most common baseline mo-
tivation behaviors were quit attempts
without treatment (N=12, 29%) and
use of medication without behavioral
treatment (N=8, 20%). Stated inten-
Table 3
Negative binomial regression predicting behavioral engagement at two months
among patients with a serious mental illness who used an electronic decision
support system on smokinga
Measure
Intercept
Diagnosis (schizophrenia versus other)
Diagnosis (alcohol versus drug disorder)
Computer use
Attitudes Towards Smoking adverse
effects subscale
Behavioral motivation index score
(baseline)
Electronic decision support system
(intervention)
a The dispersion (residual variance) from the regression model was .36±.32.
364
electronic decision support system
increased the number of expected
ways of showing motivation by a fac-
tor of 2.97 (exp=1.09), or by about
300%, holding other variables con-
Intervention (N=21) Control (N=20) stant. Because the purpose of the
system was to engage participants in
N % N %
evidence-based smoking cessation
8 38 0 — treatment, we also conducted a fol-
3 14 2 10 low-up analysis that excluded self-
5 24 0 — quit behaviors. Participants who
used the electronic decision support
2 10 0 —
12 57 6 30
system were more likely to meet
7 33 4 20 with a clinician to discuss or start
5 24 2 10 treatment (43% versus 10%; χ2=
14 67 7 35 3.84, df=4, p=.05).
9 43 2 10
Discussion
In this study, participants with severe
mental illnesses who used an elec-
tronic decision support system were
more likely to become motivated to
quit smoking over the next two
tion to quit smoking was also not dif- months than smokers who received a
ferent between the two groups at pamphlet and referral only. This
baseline. study was the first test of a newly de-
veloped electronic decision support
Outcomes system on smoking cessation for this
As shown in Table 2, at the two- population. The findings are similar
month follow-up, participants who to previous work that found that one
had used the decision support sys- (37) or four (38) sessions of in-person
tem were more likely to have en- motivational interviewing and four
gaged in at least one smoking cessa- sessions of in-person education (38)
tion motivation behavior (67%) than resulted in most schizophrenia pa-
those in the control group (35%) tients’ attending an appointment with
(χ2=4.11, df=1, p=.04). The effect of a smoking cessation provider. Even in
the electronic decision support sys- our study group, whose members had
tem remained significant in an analy- relatively little computer experience
sis that controlled for baseline group and poor computer skills, use of the
differences (Table 3). Further, this computerized tool resulted in behav-
analysis indicated that using the iors indicative of motivation. Thus the
use of a brief computer-based inter-
vention with motivational and educa-
tional components may be an effec-
tive substitute for individual sessions
with an expert clinician.
Extensive research on health be-
havior change (46–48) has shown that
Estimate SE χ2 p attitudes, perceptions of social norms,
and perceived behavioral control (or
–3.78 2.19 2.93 .09 self-efficacy) predict, at least to some
.07 .48 .02 .89 degree, motivation or intention to
–.45 .47 .91 .34
.10 .31 .11 .74 change behavior. We assessed behav-
ioral markers of motivation rather
.06 .04 2.34 .13 than psychological measures of moti-
vation, because behaviors are a
.40 .26 2.36 .12 stronger predictor of future smoking
1.05 .55 3.71 .05 cessation among persons with severe
mental illnesses (57). Change in
health behavior, including substance
PSYCHIATRIC SERVICES o ps.psychiatryonline.org o April 2011 Vol. 62 No. 4
use, has not been studied extensively
among individuals with severe mental
illnesses (58), although one study
demonstrated that attitudes, per-
ceived social norms, and perceived
behavioral control predicted antipsy-
chotic medication adherence behav-
iors in this population (59). The study
reported here was not designed to in-
vestigate the mechanisms by which
the intervention activated partici-
pants, but future work will explore
changes in attitudes, perceived social
norms, and self-efficacy for engaging
in evidence-based smoking cessation
treatment.
This pilot study was limited by sev-
eral factors: the small number of par-
ticipants, the quasi-experimental
study design that involved recruiting
participants from different types of
residences, the nonequivalent clinical
characteristics of the groups, and the
differing levels of intensity of the ex-
perimental and control interventions.
As with all studies using quasi-experi-
mental designs, this study does not
rule out the possibility that the find-
ings are a result of site differences. In
addition, we did not correct for mul-
tiple tests. Nonetheless, this study is
the beginning of a stepwise approach
to the development of a brief Web-
based intervention.
Conclusions
The encouraging results of this pilot
study indicate that electronic decision
support systems may facilitate the use
of evidence-based smoking cessation
treatments by people with severe
mental illnesses. To confirm and ex-
tend these findings, future work
should use larger study groups, ran-
domized controlled trials, comparison
conditions matched for intensity,
longer follow-ups to assess smoking
abstinence, and methods that would
allow exploration of mechanisms of
behavior change.
Acknowledgments and disclosures
This research was supported by the West Fam-
ily Foundation and the Segal Foundation.
The authors report no competing interests.
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