People with severe mental ill health are more likely to smoke than those in the general population. It is therefore important that effective smoking cessation strategies are used to help people with severe mental ill health to stop smoking. This study aims to assess the effectiveness and cost –effectiveness of smoking cessation and reduction strategies in adults with severe mental ill health in both inpatient and outpatient settings. This is an update of a previous systematic review. Electronic databases were searched during September 2016 for randomised controlled trials comparing smoking cessation interventions to each other, usual care, or placebo. Data was extracted on biochemically-verified, self-reported smoking cessation (primary outcome), as well as on smoking reduction, body weight, psychiatric symptom, and adverse events (secondary outcomes). We included 26 trials of pharmacological and/or behavioural interventions. Eight trials comparing bupropion to placebo were pooled showing that bupropion improved quit rates significantly in the medium and long term but not the short term (short term RR = 6.42 95% CI 0.82–50.07; medium term RR = 2.93 95% CI 1.61–5.34; long term RR = 3.04 95% CI 1.10–8.42). Five trials comparing varenicline to placebo showed that that the addition of varenicline improved quit rates significantly in the medium term (RR = 4.13 95% CI 1.36–12.53). The results from five trials of specialised smoking cessation programmes were pooled and showed no evidence of benefit in the medium (RR = 1.32 95% CI 0.85–2.06) or long term (RR = 1.33 95% CI 0.85–2.08). There was insufficient data to allowing pooling for all time points for varenicline and trials of specialist smoking cessation programmes. Trials suggest few adverse events although safety data were not always reported. Only one pilot study reported cost effectiveness data. Bupropion and varenicline, which have been shown to be effective in the general population, also work for people with severe mental ill health and their use in patients with stable psychiatric conditions. Despite good evidence for the effectiveness of smoking cessation interventions for people with severe mental ill health, the percentage of people with severe mental ill health who smoke remains higher than that for the general population.

Summary: During COVID-19, health provision and information resources have been increasingly provided via digital means (e.g. websites, apps) and this will become a standard practice beyond the pandemic. People with severe mental illness face profound health inequalities (e.g. a >20-year mortality gap). Digital exclusion puts this population at risk of heightened or compounded inequalities. This has been referred to as the ‘digital divide’. For any new digital means introduced in clinical practice to augment healthcare service provision, issues of accessibility, acceptability and usability should be addressed by researchers and developers early in the design phase, and prior to full implementation, to prevent digital exclusion.

Background and Aims: People with severe mental ill health smoke more and suffer greater smoking‐related morbidity and mortality. Little is known about the effectiveness of behavioural interventions for smoking cessation in this group. This review evaluated randomized controlled trial evidence to measure the effectiveness of behavioural smoking cessation interventions (both digital and non‐digital) in people with severe mental ill health.Design: Systematic review and random‐effects meta‐analysis. We searched between inception and January 2020 in Medline, EMBASE, PsycINFO, CINAHL, Health Management Information Consortium and CENTRAL databases.Setting and participants: Randomized controlled trials (RCTs) assessing the effects of behavioural smoking cessation and reduction interventions in adults with severe mental ill health, conducted in any country, in either in‐patient or community settings and published in English.Measurements: The primary outcome was biochemically verified smoking cessation. Smoking reduction and changes in mental health symptoms and body mass index (BMI) were included as secondary outcomes. Narrative data synthesis and meta‐analysis were conducted and the quality of included studies was appraised using the risk of bias 2 (RoB2) tool.Findings: We included 12 individual studies (16 articles) involving 1861 participants. The first meta‐analysis (three studies, 921 participants) demonstrated effectiveness of bespoke face‐to‐face interventions compared with usual care across all time‐points [medium‐term: relative risk (RR) = 2.29, 95% confidence interval (CI) = 1.38–3.81; long‐term: RR = 1.58, 95% CI = 1.09–2.30]. The second (three studies, 275 participants) did not demonstrate any difference in effectiveness of bespoke digital on‐line interventions compared with standard digital on‐line interventions (medium‐term: RR = 0.87, 95% CI = 0.17–4.46). A narrative overview revealed mixed results when comparing bespoke face‐to‐face interventions with other active interventions. The methodological quality of studies was mixed, with the majority having some concerns mainly around risk of selective reporting.Conclusions: Face‐to‐face bespoke smoking cessation interventions for adults with severe mental ill health appear to be effective when compared with treatment as usual, but evidence is equivocal when compared with other active interventions. There is limited evidence comparing bespoke digital interventions with generic interventions, and we found no studies comparing them with usual treatment.

People with severe mental illness suffer from a high burden of oral diseases, which can negatively impact their physical and mental well-being. Despite the high burden, they are less likely to engage in oral health care including accessing dental services. We aimed to identify both the service users’ and service providers’ perspective on the barriers and facilitators for maintaining oral health and dental service use in people with severe mental illness. Qualitative exploration was undertaken using dyadic or one-to-one in-depth interviews with service users in the UK with a diagnosis of schizophrenia, schizoaffective disorder or bipolar disorder. Service providers, including mental health and dental health professionals, and informal carers (people identified as family or friend who are not paid carers) were also interviewed. Thematic analysis of the data revealed three main cross-cutting themes at the personal, inter-personal and systems level: amelioration of the problem, using a tailored approach and provision of comprehensive support. The main barriers identified were impact of mental ill-health, lack of patient involvement and tailored approach, and accessibility and availability of dental services including lack of integration of services. The main facilitators identified were service providers’ effective communication skills and further support through the involvement of carers. The findings suggest that the integration of dental and mental health services to provide tailored support for overall health and well-being, including the oral health of the patient, can better support people with severe mental illness regarding their oral health needs.

Obsessive-compulsive disorder (OCD) is prevalent and without adequate treatment usually follows a chronic course. “High-intensity” cognitive-behaviour therapy (CBT) from a specialist therapist is current “best practice.” However, access is difficult because of limited numbers of therapists and because of the disabling effects of OCD symptoms. There is a potential role for “low-intensity” interventions as part of a stepped care model. Low-intensity interventions (written or web-based materials with limited therapist support) can be provided remotely, which has the potential to increase access. However, current evidence concerning low-intensity interventions is insufficient. We aimed to determine the clinical effectiveness of 2 forms of low-intensity CBT prior to high-intensity CBT, in adults meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for OCD. This study was approved by the National Research Ethics Service Committee North West–Lancaster (reference number 11/NW/0276). All participants provided informed consent to take part in the trial. We conducted a 3-arm, multicentre randomised controlled trial in primary- and secondary-care United Kingdom mental health services. All patients were on a waiting list for therapist-led CBT (treatment as usual). Four hundred and seventy-three eligible patients were recruited and randomised. Patients had a median age of 33 years, and 60% were female. The majority were experiencing severe OCD. Patients received 1 of 2 low-intensity interventions: computerised CBT (cCBT; web-based CBT materials and limited telephone support) through “OCFighter” or guided self-help (written CBT materials with limited telephone or face-to-face support). Primary comparisons concerned OCD symptoms, measured using the Yale-Brown Obsessive Compulsive Scale–Observer-Rated (Y-BOCS-OR) at 3, 6, and 12 months. Secondary outcomes included health-related quality of life, depression, anxiety, and functioning. At 3 months, guided self-help demonstrated modest benefits over the waiting list in reducing OCD symptoms (adjusted mean difference = −1.91, 95% CI −3.27 to −0.55). These effects did not reach a prespecified level of “clinically significant benefit.” cCBT did not demonstrate significant benefit (adjusted mean difference = −0.71, 95% CI −2.12 to 0.70). At 12 months, neither guided self-help nor cCBT led to differences in OCD symptoms. Early access to low-intensity interventions led to significant reductions in uptake of high-intensity CBT over 12 months; 86% of the patients allocated to the waiting list for high-intensity CBT started treatment by the end of the trial, compared to 62% in supported cCBT and 57% in guided self-help. These reductions did not compromise longer-term patient outcomes. Data suggested small differences in satisfaction at 3 months, with patients more satisfied with guided self-help than supported cCBT. A significant issue in the interpretation of the results concerns the level of access to high-intensity CBT before the primary outcome assessment. We have demonstrated that providing low-intensity interventions does not lead to clinically significant benefits but may reduce uptake of therapist-led CBT. International Standard Randomized Controlled Trial Number (ISRCTN) Registry ISRCTN73535163.