Regular articles Carbon monoxide feedback in a motivational decision support system for nicotine dependence among smokers with severe mental illnesses Mary F. Brunette, M.D. a, ⁎, Joelle C. Ferron, Ph.D. a , Robert E. Drake, M.D., Ph.D. a , Timothy S. Devitt, Psy.D. b , Pamela T. Geiger, B.A. a , Gregory J. McHugo, Ph.D. a , Jessica A. Jonikas, M.A. c , Judith A. Cook, Ph.D. c a Geisel School of Medicine at Dartmouth and Dartmouth Psychiatric Research Center, Concord, NH 03301, USA b Thresholds, 4101 North Ravenswood, Chicago, IL 60613, USA c University of Illinois at Chicago School of Public Health/Psychiatric Institute, Chicago, IL 60612, USA abstract article info Article history: Received 14 November 2012 Received in revised form 13 March 2013 Accepted 15 April 2013 Keywords: Nicotine dependence Severe mental illness Motivation Smoking cessation Treatment Schizophrenia Health concerns are common reasons for wanting to quit smoking among smokers with mental illnesses. Motivational interventions have used feedback from a carbon monoxide monitor to increase awareness of health concerns, but this device is not commonly available. Whether brief motivational interventions can be effective without this feedback is unknown. Using a randomized controlled trial, this study tested the effect of carbon monoxide feedback within a brief, multi-component, computerized motivational intervention among 124 smokers with schizophrenia or mood disorders. The main outcome was initiating cessation treatment over two months. Although participants in the carbon monoxide group increased their knowledge about the carbon monoxide, (χ 2 = 6.97, df = 1, p = .008), the main and secondary outcomes did not differ significantly between groups. Overall, 32% of participants initiated treatment. This study suggests that a computerized motivational decision support system can lead users to initiate cessation treatment, and that carbon monoxide feedback is not a necessary component. © 2013 Elsevier Inc. All rights reserved. 1. Introduction Among smokers in the general population and smokers with mental illnesses, a commonly cited reason for wanting to quit smoking is a health concern (McCaul et al., 2006; Morris, Waxmonsky, May, & Giese, 2009; Nawaz, Frounfelker, Ferron, Carpenter-Song, & Brunette, 2012). Negative health events such as a diagnosis of emphysema often lead to smoking cessation (Sloan, Smith, & Taylor, 2003; Wray, Herzog, & Willis, 1998). People with severe mental illnesses such as schizophrenia and severe mood disorders experience high rates of health consequences (Birkenaes et al., 2007; Dickey, Normand, Weiss, Drake, & Azeni, 2002; Himelhoch et al., 2004) and early mortality (Brown, Inskip, & Barraclough, 2000) due in part to very high rates of smoking. But, they tend to have low awareness of the relationship between specific common health problems, such as hypertension, and smoking (Lucksted, McGuire, Postrado, Kreyen- buhl, & Dixon, 2004; Morris et al., 2009). Motivational interventions for smoking cessation typically attempt to increase awareness of the health risks of smoking in order to encourage people to quit. One study of motivational interviewing for smokers with schizophre- nia used feedback from a health problem checklist and from a carbon monoxide monitor to increase awareness and motivation. This study found that 28% of those who received the intervention attended a first session of cessation treatment compared to 0% of controls who received no intervention (Steinberg, Ziedonis, Krejci, & Brandon, 2004). The carbon monoxide monitor provides a quantitative measure of the level of carbon monoxide, a cigarette smoke toxin, in the breath. This reading may serve to personalize and heighten awareness of the negative health effects of smoking on the body. Heightening the focus on health effects by giving feedback may particularly benefit people with schizophrenia and severe mood disorders given that attention impairments are associated with these disorders (Reichenberg et al., 2009). Although carbon monoxide monitor feedback has been a component of motivational interventions for smokers with severe mental illnesses (Cather et al., 2010; Steinberg et al., 2004; Williams et al., 2010; Williams, Ziedonis, Vreeland, & Speelman-Edwards, 2009), including a computerized motivational decision support system we developed (Brunette, Ferron, McHugo, et al., 2011), research on the effect of carbon monoxide monitor feedback as a stand-alone intervention on smoking outcomes in the general population has been equivocal (Bize, Burnand, Mueller, & Cornuz, 2009; McClure, Ludman, Grothaus, Pabiniak, & Richards, 2009). Further, this type of feedback has not been used in many of the motivational interventions used in the general population (Lai, Cahill, Qin, & Tang, 2010). These monitors are expensive (the Smokerlyzer Journal of Substance Abuse Treatment 45 (2013) 319–324 ⁎ Corresponding author. Dartmouth Psychiatric Research Center, Concord, NH 03301. E-mail address: Mary.F.Brunette@Dartmouth.Edu (M.F. Brunette). 0740-5472/$ – see front matter © 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jsat.2013.04.005 Contents lists available at SciVerse ScienceDirect Journal of Substance Abuse Treatment