An interview with Dr. Kelly Arbour-Nicitopoulos

Dr. Arbour-Nicitopoulos is a postdoctoral fellow in the Faculty of Physical Education and Health at the University of Toronto. Her research focuses on understanding multiple changes in health behaviour, in particular physical activity, healthier eating, and smoking cessation, within underserved populations. Over the past three years, she has examined the psychosocial and environmental factors associated with physical activity in persons living with an injured spinal cord. Currently, Dr. Arbour-Nicitopoulos is conducting research on the use of physical activity as a strategy for facilitating smoking cessation and healthy eating in women with severe mental illness.

1. Can you describe your research interests?

I have two types of research programs going on. The first program examines multiple health-behaviour change in women with mental illness. My expertise is in physical activity and I am relating behaviour-change principles to other health behaviours, specifically smoking cessation and healthy eating. For my qualitative study, I have interviewed women with serious mental illness and looked at the acceptability of physical activity as an adjunctive treatment for smoking cessation.

The response from the women was overwhelming: physical activity is important to them and would be an acceptable strategy for promoting smoking cessation.

The issues that came up were affordability, not knowing where to go, and concerns relating to body image. This has implications for how we can develop physical activity and other healthy lifestyle programs that are sustainable in women with mental illness.
My second research area is in spinal cord injury and using theory-based best practice for promoting physical activity. I have been applying the work that I have done with persons with spinal cord injury to promoting healthy behaviours among persons with mental illness.

2. Can you describe your research on physical activity and smoking cessation?

I conducted interviews with a representative sample of 12 female patients with serious mental illness who were seeking cessation treatment through a smoking cessation clinic at the Centre for Addiction and Mental Health. In the interview we asked about the types of physical activity of interest, the barriers and coping strategies for participation, and the role of health-care professionals in delivering a physical activity-based smoking cessation program. This study is part of a collaboration between myself, Guy Faulkner at the University of Toronto, [and] Tony Cohn and Peter Selby, both of whom are from the Centre for Addiction and Mental Health, specializing in the areas of psychiatry and addiction, respectively.

Guy Faulkner, Tony Cohn and myself are also working with people with schizophrenia who are in the Healthy Lifestyle Promotion Program (HELPP) at the Mental Health and Metabolism Clinic at CAMH [the Centre for Addiction and Mental Health]. This program is part of a service that is offered at the clinic, in which we are developing a manual so that one day the program can be implemented in similar settings elsewhere.

The HELPP program consists of a dietitian and recreation therapist leading a six-week women's (only) group-based program where they meet with women with schizophrenia twice a week for one hour, each session. There is an educational component, which involves teaching the women how to overcome barriers to healthy eating and physical activity, as well as helping them develop skills [that] can be applied to different behaviours involving strategizing and problem-solving. The dietitian helps in monitoring diets and providing healthy nutrition options. There is support for such habits as planning and self-regulation. The recreational therapist offers introductions to activities that can also be done at home such as yoga, group walks and resistance training with soup cans.

So far, we have examined changes before and after the HELPP program in domains such as eating and physical-activity patterns, confidence in regulating healthy eating habits and physical activity, perceptions in physical appearance and functioning, and overall quality of life. After six weeks, there was a slight increase in moderate physical activity (such as walking), a decrease in consumption of pop and juice, an increase in fruit and vegetable consumption, improved satisfaction with physical functioning and appearance, increased confidence to regulate healthy eating and physical activity, and improved quality of life, particularly social functioning.

These processes that lead to such things as improved body image and self-confidence in one's abilities can lead to behaviour change.

The HELPP program so far has included 30 women with schizophrenia who are obese or overweight. We're working toward testing the effectiveness in a larger study, which would include obtaining feedback from service providers such as physical-activity programmers at the YMCA and program providers at in-patient hospital centres.

3. What were the barriers for participants to be physically active?

One common barrier was a lack of affordable access to or knowledge of community-based programs.

Other chronic health conditions were a barrier, such as pre-existing emphysema, chronic obstructive pulmonary disease, bronchitis, arthritis, and cancer. It was hard for those with these conditions to get started, because they did not want to make their conditions worse. Other short-term conditions came up: one woman coughed up phlegm when exercising, so she needed positive reinforcement to push through and get past this stage of quitting.

Cost is another barrier to joining a gym or even to go to the YMCA. You still need to think about the cost of footwear, apparel, transportation, etc.

Some also spoke of body-image issues such as not wanting to exercise in front of other people. Some wanted to be with people who were similar to themselves (e.g., other women who were trying to quit smoking and/or who had an underlying mental health condition), and not in an environment where they felt threatened (e.g., in an exercise class with younger participants who were perceived as being thin).

4. How do these barriers relate to smoking cessation as well?

Up to 90 percent of people with schizophrenia smoke. Hence, the qualitative study examined the use of physical activity as a smoking cessation strategy for women who either were trying to quit or had quit recently.

Activities that were very popular among the study participants included yoga, walking, swimming, cycling, weight training [and] going out into nature.

I'm an exerciser, but even I find that after a while, exercise can become monotonous if you do not include a little variety in your routine. While walking may be the most practical and feasible type of physical activity for persons with mental illness, we have to be creative with the programming for these individuals, especially if we want them to adhere over the long term. Even yoga can be done with small groups, which can add some variety.

The social environment is also very important, to make sure that after the physical activity the person does not go out for a cigarette. Smokers who are interested [in quitting] or who are trying to quit need all of the support they can get. Being a part of a physical activity group or program may provide one source of support for them.

5. Can exercise help with cravings?

More than cravings, physical activity can help with managing one's mood, which can be a trigger for smoking. Physical activity can also help with weight management. Some of the participants in the qualitative study said that physical activity should be better promoted as a way to quit and manage the potential weight gain that is often associated with quitting smoking.

6. Did you find any concerns about interactions of medications with participation in a program?

A few of the women mentioned issues related to medications and feeling lethargic, which in turn could make it difficult to exercise. I'm not a physiologist, so I'm not sure about the interaction between smoking and medication.

We discovered that we could not have the program run in the morning; medications can make it harder to get ready in the morning: 11 a.m. was too early; 2 p.m. worked better. This is similar to the spinal-cord injury population, where it can take some individuals three or more hours to complete their morning routine. These types of things need to be taken into account for programming.

7. What was the role of diet in smoking cessation?

Although the study focused on physical activity, many spoke of diet as a part of the holistic approach to smoking cessation.

People tend to eat more when quitting. As a programmer, it would be ideal to try to replace time of cigarette-smoking with programming. Healthy snacks can be chosen over unhealthy ones. The dietitian in the HELPP program would suggest strategies such as replacing pop with diet pop or crystals for flavouring water, and how to monitor serving sizes. When we start talking about physical activity, people seem to also be interested in diet.

8. Do you think there would be a different approach for a physical activity program that incorporates smoking cessation, or vice-versa?

You would want to bring in expertise in both physical activity and smoking cessation to have collaboration between the two areas. With smoking cessation, you would need to know about changes in the body. A recreational therapist would likely have expertise in both areas.

9. Do you have recommendations for resources on smoking cessation for people with serious mental illness?

The Nicotine Dependence Clinic at CAMH has amazing therapists and physicians. They have expertise as well as many resources relating to smoking cessation. The clinic staff could direct programmers to specific smoking-cessation resources. I feel that this clinic would provide a greater collaboration opportunity for physical activity programmers. The clinic manager is Rosa Dragonetti. Her e-mail is Rosa_Dragonetti [AT] camh.net.

10. Any final thoughts?

Physical activity can be an affordable option for facilitating smoking cessation, in conjunction with other standard treatment such as nicotine replacement therapy, in women with severe mental illness. More importantly, physical activity can help people manage negative mood and promote more positive feelings over the long term. Ultimately, this will provide people with a sense of control over their ability to stay smoke-free as well as to lead more healthy lifestyles.

If there are any further questions that any readers may have, they can e-mail me at kelly [dot] arbour [at] utoronto [dot] ca.