PROJECT SUMMARY/ABSTRACT
Among the 51.5 million US adults with mental illness (MI), over 18 million smoke cigarettes, 7-9,50-52 leading to
high morbidity60-62 and dramatic early mortality.12-14 Smokers with MI are less likely to quit and/or sustain
abstinence than smokers without MI,17-21 due in part to lower self-efficacy65 and more use of smoking to cope
with stress.67-69 Lower levels of readiness to pursue smoking cessation treatments,64,66 most of which require a
desire for complete abstinence, leaves most smokers with MI continuing to smoke, creating an urgent need to
develop new ways to decrease the harms from cigarettes. Tobacco harm reduction is not clearly defined, but it
involves a value-neutral view of smoking, focused on decreasing the harms from tobacco use, neither objecting
to nor insisting on abstinence as the only goal.71 E-cigarettes (e-cigs) deliver much lower levels of carcinogens
than cigarettes;72,73 thus, support for replacement of most or all cigarettes with e-cigs (“switching”) may be an
effective harm reduction strategy for smokers with MI. Three pilot studies found that providing e-cigs to
smokers with MI significantly reduced use of cigarettes (up to 65%),34-36 and 10-14.3% of smokers replaced
their cigarettes with e-cigs.34,35 In the only RCT comparing e-cig provision to smoking-as-usual in smokers with
MI (R01DA041416), we found that 18.6% of the e-cig group switched to e-cigs, 46% reduced to ≤5 cigs/day,
and NNAL, a potent carcinogen, was significantly reduced.3 But, many smokers did not achieve harm reduction
with e-cig provision alone. Feedback from participants indicated that a key barrier to giving up cigarettes was
the habitual use of cigarettes when under stress. This study responds to PAR-22-182’s call for “research
on tobacco harm reduction strategies such as switching from combustibles to e-cigarettes.”
We developed and piloted “SWITCH IT,” consisting of behavioral support to boost e-cig use and manage
stress, for smokers with MI who are not ready to quit. SWITCH IT was delivered to 50 smokers with MI via 10
video calls. Attendance was 90.3%, indicating high appeal of behavioral support. Twice as many smokers
(38% vs. 19%) switched to e-cigs (confirmed by breath CO<10 ppm) compared to the e-cig group in our RCT.
We now propose to test the effect of SWITCH IT on “switching” using several measures of harm reduction (≤5
cigs/day and CO<10; 0 cigs/day and CO<6, and NNAL). We will also explore potential barriers to switching
(cravings, positive and negative affect, e-cig satisfaction) and possible mechanisms of behavioral change from
SWITCH IT (coping with stress without smoking, and self-efficacy). Finally, we will explore the role of e-cigs in
switching by comparing trajectories of change in cigarette and e-cig use over time. We will assign 250 smokers
with MI in 2 US states to receive SWITCH IT and an 8-week supply of e-cigs or e-cigs only. Participants will be
assessed at BL, 2, 4, 6, 8, 12, and 26 weeks. This project would break new ground and advance the field
of tobacco harm reduction by empirically exploring definitions of harm reduction and “switching,” and testing
the efficacy of using behavioral support for e-cig use to augment harm reduction in smokers with MI.
