Acceptability of integrating smoking cessation treatment into routine care for people with mental illness: A qualitative study

Abstract Introduction Improving Access to Psychological Therapies (IAPTs) Services could offer smoking cessation treatment to improve physical and psychological outcomes for service users, but it currently does not. This study aimed to understand participants' views and experiences of receiving a novel smoking cessation intervention as part of the ESCAPE trial (intEgrating Smoking Cessation treatment As part of usual Psychological care for dEpression and anxiety). We used the Capability, Opportunity and Motivation Model of Behaviour (COM‐B) to understand the (i) acceptability of the integrated smoking cessation treatment, (ii) views of psychological well‐being practitioners' (PWPs) ability to deliver the smoking cessation treatment and (iii) positive and negative impacts of smoking cessation treatment. Methods This was a qualitative study embedded within a feasibility randomized‐controlled trial (ESCAPE) in primary care services in the United Kingdom (IAPT). Thirty‐six participants (53% female) from both usual care and intervention arms of the ESCAPE trial, including both quitters and nonquitters, were interviewed using semi‐structured interviews. Data were analysed using a framework approach to thematic analysis, using the COM‐B as a theoretical frame. Results Psychological Capability: Integrated smoking cessation treatment was acceptable and encouraged participants to reflect on their mental health. Some participants found it difficult to understand nicotine withdrawal symptoms. Motivation: Participants were open to change during the event of presenting to IAPT. Some described being motivated to take part in the intervention by curiosity, to see whether quitting smoking would help their mental health. Physical Opportunity: IAPT has a natural infrastructure for supporting integrated treatment, but there were some barriers such as session duration and interventions feeling segmented. Social Opportunity: Participants viewed PWPs as having good interpersonal skills to deliver a smoking cessation intervention. Conclusion People with common mental illness generally accepted integrated smoking cessation and mental health treatment. Smoking cessation treatment fits well within IAPT's structure; however, there are barriers to implementation. Patient or Public Contribution Before data collection, we consulted with people with lived experience of smoking and/or mental illness and lay public members regarding the aims, design and interview schedules. After analysis, two people with lived experience of smoking and mental illness individually gave feedback on the final themes and quotes.


| INTRODUCTION
Smoking is the world's leading cause of cancer and death worldwide. 1-3 People with common mental illness, such as depression and anxiety, are twice as likely to smoke than those without common mental illness. In the United Kingdom, smoking prevalence in people with depression or anxiety is 32% compared to 14.1% in the general population. 4,5 People with mental illnesses have a 19% reduction in the odds of achieving abstinence when trying to quit, 6 but are as motivated to quit as those without mental illness. 7 These differences increase mortality in people with mental illness when compared to the general population resulting from cancer (mortality rate ratio: 1.92; 95% confidence interval [CI]: 1.91-1.94) 8 and cardiovascular disease (mortality hazard ratio: 1.85; 95% CI: 1.53-2.24). 9 Integrating cessation treatment into mental health settings could prevent 78,000 deaths in the next 80 years. 10 People with mental illness may use smoking to try to alleviate symptoms, for example, using smoking to relax when they feel anxious; 11 recent evidence suggests that this is counter-productive, as smoking can in fact exacerbate and maintain mental health symptoms, and stopping smoking can improve mental health. [12][13][14][15] Qualitative studies suggest that although people with mental illness do report perceived benefits of smoking, they also accept evidence that smoking tobacco may harm mental health, and quitting might benefit mental health, and suggest that framing cessation as a treatment for mental health could motivate them to quit. 11 A cochrane review of smoking cessation treatments for people with current and historical depression found that adding psychosocial mood management to usual smoking cessation treatment (e.g., nicotine replacement therapy) increased cessation rates when compared to usual smoking treatment alone (risk ratio: 1.47; 95% CI: 1. 13-1.92). In the United Kingdom, people with depression/ anxiety can access psychological therapy services, known as 'Improving Access to Psychological Therapies' (IAPTs), in which service users receive evidence-based therapies to improve mood and well-being. IAPT receives over 1.5 million referrals a year, 16 and could offer smoking cessation treatment, but it currently does not.
Integrating smoking cessation support within IAPT treatment for mental illness could improve physical and psychological outcomes for its service users. The World Health Organization recommends that countries integrate smoking cessation interventions into primary care services, such as IAPT. 17 Qualitative studies embedded within randomized-controlled trials (RCTs) provide the potential to gain new understandings of participant experiences of an intervention and inform the development of future interventions. 18 We have recently codesigned a smoking cessation intervention with IAPT staff and service users, and are testing the intervention in a large, acceptability and feasibility pilot RCT. 11,19 We conducted interviews with trial participants to understand their experiences and views of the integrated smoking cessation intervention. We used the Capability, Opportunity and Motivation Model of Behaviour (COM-B) 20 to understand the: 1. Acceptability of the integrated smoking cessation treatment.
2. Views of psychological well-being practitioners' (PWPs') ability to deliver the smoking cessation treatment.
3. Positive and negative impacts of smoking cessation treatment.

| METHODS
This study was embedded within a feasibility RCT, prospectively registered on the ISRCTN registry (ISRCTN99531779). 19

| Setting and participants
We conducted semi-structured interviews with IAPT service users taking part in the ESCAPE Trial, involving four NHS trusts in the United Kingdom. Further details are described in the study protocol. 19 In the ESCAPE Trial, intervention and control groups

| Recruitment procedure
We used a convenience sampling method. During trial follow-up, we asked participants if they would like to take part in an interview about their experience in the study. Participants who had withdrawn from the study or did not complete follow-ups were not approached for an interview. Informed consent was obtained verbally and recorded at the start of the interview; there was no written consent. The information sheet for the qualitative interviews was combined with the main trial information sheet.
To ensure confidentiality, with informed consent from participants, interviews were recorded using an encrypted digital voice recorder, transcribed and anonymized. Any identifying information in the transcripts was removed, but considering the risk of reidentification, researchers involved in the study were bound to confidentiality regulations set by the University of Bath and NHS. To further protect confidentiality, access to anonymized transcript data is restricted to only approved bona fide researchers after application to the University of Bath's Research Data Archive.

| Sample size and selection criteria
For entry into the trial, participants fulfilled the eligibility criteria for IAPT and were daily tobacco smokers (see the trial protocol for details 19 ). All trial participants were eligible for inclusion in the qualitative interviews, regardless of whether they had quit smoking or not during their participation in the trial; the final sample included both quitters and nonquitters.
We aimed to achieve strong information power. 23 Information power was used based on the aim of the study being broad, sample specificity being moderate, use of applied theoretical frameworks (COM-B), with moderate quality of dialogue, and a case and crosscase analysis strategy. 23 We agreed as a team that we reached strong information power at 36 participants.

| Interviews
Interviews were conducted between October 2018 and February 2021 over the telephone and lasted approximately 30-60 min. We used flexible interview schedules and open-ended questioning (Supporting Information: Appendix S1). Interview schedules were modified as necessary throughout the course of the interviews to explore newly occurring concepts and experiences. Interviewers (K. S. and K. F. S.) kept notes to capture any relevant codes or concepts for analysis. Participants were not paid for the interview.

Analytic approach
Two researchers (K. S. and G. T.) conducted the analysis and held a critical realist perspective. Data were analysed using a framework approach to thematic analysis, following Braun and Clarke's 24 method, with both deductive and inductive coding. This method was chosen as we aimed to compare the commonalities and differences in experiences of integrated treatment and relationships between experiences, both across cases and within individual cases. 25 Deductive codes were informed by the COM-B where appropriate; if constructs of the COM-B were not identified in the data, they were not included in the final theme structure. 20 Inductive codes were data-driven and remained close to participants' language where possible. An example of data coded inductively and deductively can be found in Supporting Information: Appendix S2.
The software used for data analysis were Microsoft Word and Excel.
Coding process and how themes were identified One researcher (K. S.) read each transcript and listened to the audio recordings, followed by inductive line-by-line coding. After coding three transcripts, K. S. iteratively developed a data-driven coding frame and sought feedback from the second researcher (G. T.). K. S. then grouped codes into categories, providing a working analytical framework that reflected the aims of the study, which were reviewed with G. T., and some inductive codes were added. K. S. then deductively coded the data based on the concepts from the COM-B model, with some data being coded both inductively and deductively.
K. S. then actively identified themes relating to study objectives, developed around the COM-B model, which were reviewed and agreed with the wider team.

Reflexivity
Being aware of our own bias as researchers running and working on the ESCAPE trial, K. S. and G. T. kept notes and regularly checked in to discuss bias and the codes/themes being identified. Being aware of our own biases towards believing that the trial/therapy might succeed, we aimed to ensure that both positive and negative experiences and any deviant experiences are reflected in the results, such that themes are not necessarily all based on number. K. S. and G. T. both identify as females, K. S. has never smoked, G. T. is an exsmoker and K. S. and G. T. have not received mental health therapy in IAPT before.

| Patient and public involvement
Before data collection, we consulted with people with lived experience of smoking and/or mental health problems and lay public members regarding the design of aims and interview schedules. After analysis, two people with lived experience of smoking and mental illness individually gave feedback on the final themes and quotes.

| Participant characteristics
We invited 49 trial participants to take part in qualitative interviews.
Thirteen declined to participate or did not answer recruitment calls, with the remaining 36 completing an interview at either the 3-month or the 6-month follow-up, one person requested to be interviewed at both the 3-and 6-month follow-up time points. The mean age of the participants was 36.89 years (range: 20-65), 19/36 (53%) were female and the majority were White (92%) ( The smoking cessation intervention fitted will within IAPT's delivery method of treatment programmes. Participants described how they found having integrated treatment over the phone 'helpful' and easier to fit into their daily lives.

| Subtheme 3.2: Service-level barriers to integrated treatment
Some participants described how the length of time between appointments was too long and appointments were needed more frequently. Some participants described how there was a lot of content to fit into the appointments, which were often quite short.
One participant described how they could sense their session was coming to an end as they felt their therapist was getting 'stressed trying to fit everything into their appointment'. smoking as a coping mechanism in the context of their anxiety.
Having the integrated treatment was described as a more positive and helpful experience than smoking cessation treatment alone.
Participants described how their PWPs encouraged them to make decisions and choices in their quit attempt, being guided in an encouraging and positive manner. Participants also emphasized how having to check in with their therapist regularly prompted them to remain abstinent from smoking as they did not want to let them down. Participants described how they were encouraged when they had had a 'slip up'.
She was very gentle, and I think she was very encouraging and very positive, but it was very much, I feel it was subtly getting me to make the decisions and getting me to make the choices, while acknowledging that these are all going to be good, she never actually Participants also felt like their smoking cessation support was tailored to them, compared to people who accessed an NHS stop smoking service, who felt like they were treated as a 'generic smoker', for example, being provided with information about the products available rather than identifying what would work for them as an individual.

| Summary
We aimed to understand the experience of an integrated smoking cessation and mental health treatment among people with common mental illness. We found that generally, people with mental illness accepted integrated smoking cessation and mental health treatment, and had the psychological capability, motivation, physical and social opportunity to accept and engage with the integrated treatment. However, participants also faced several barriers in understanding tobacco withdrawal and at the service level.
Participants described how PWPs had the interpersonal skills for delivering the smoking cessation intervention, but it sometimes seemed scripted or unnatural. The benefits of a critical realist perspective are that we can understand the relationship between context (the setting of an intervention), mechanisms (things that cause change) and the outcome or experience of an intervention. 31 Therefore, by using this perspective, we were able to understand how the experience of the smoking cessation intervention integrated within an IAPT service was influenced by the context in which it was experienced, and why or why not it was accepted in this environment.

| Comparison with the existing literature
Integrated smoking cessation and mental health treatment was generally accepted, and participants had the capability to understand their smoking behaviour in the context of the tobacco withdrawal cycle and engage in treatment. These findings further those from our qualitative study of IAPT patients' views of integrated treatment, which found that IAPT patients accepted evidence that smoking may worsen their mental health and that quitting could improve their mental health. 11 However, similar to other research, some participants described how they used smoking as a coping mechanism and prioritized their mental health treatment over quitting smoking. 34,35 Although most participants described their smoking using a CBT model and identified withdrawal as a component of their mental illness, some participants described withdrawal and mental illness as different experiences. This contrasts with the literature on the tobacco withdrawal cycle, which suggests that irritability and low mood from nicotine withdrawal are the same experience as mental illness. 36,37 This study found that an important factor for smoking cessation intervention uptake is having smoking cessation treatment available and offered in primary care services. This finding is in line with a systematic review that found that offering all smokers help to quit increased quit attempts, compared to telling them to quit. 38 This study supports findings from our recent study, which suggests that IAPT services could be a suitable infrastructure for smoking cessation treatment, but there may be some service-level barriers. 11 Similar to a qualitative study of smoking cessation therapy for people with severe mental illness, we found that service users viewed PWPs as having good interpersonal skills to deliver smoking cessation interventions. 39 Participants were motivated to accept and engage with the integrated smoking cessation and IAPT therapy, consistent with a systematic review indicating that people with mental illness are motivated to quit smoking. 7 Participants stated that receiving smoking cessation treatment at the same time as mental health treatment was 'a good a time as any'. These findings challenge health care professionals' views that quitting smoking at the same time is too much for people with mental illness. 35,40 Previous literature has suggested that altruism is an important motivator for participation in mental health trials. 41,42 The key motivators for engagement identified in the present study were participants' openness to change and curiosity regarding the potential impact of the combined treatment approach for smoking and their mental health. These motivations reflect a primary interest in the personal benefits of taking part rather than a desire to help others.
These findings are consistent with the idea of 'conditional altruism', 43,44 which suggests that an interest in helping others may facilitate initial engagement; however, an expectation of some personal benefit is an important driver for enrolment and subsequent participation in trials.

| Implications for research and practice
Integrating the NCSCT's standard treatment programme for smoking cessation 22