Evidence-Based Reviews

Strategies to help patients break the chains of tobacco addiction

Current Psychiatry. 2011 August;10(8):41-49

References

1. Colton CW, Manderscheid RW. Congruencies in increased mortality rates years of potential life lost, and causes of death among public mental health clients in eight states. Prev Chronic Dis. 2006;3(2):A42.-

2. Centers for Disease Control and Prevention. Trends in state and federal cigarette tax and retail price—1970-2009. 2010. Available at: http://www.cdc.gov/tobacco/data_statistics/tables/economics/trends. Accessed June 28 2011.

3. Xian H, Scherrer JF, Eisen SA, et al. Nicotine dependence subtypes: association with smoking history, diagnostic criteria and psychiatric disorders in 5440 regular smokers from the Vietnam Era Twin Registry. Addict Behav. 2007;32(1):137-147.

4. Fiore MC, Jaén CR, Baker TB, et al. A clinical practice guideline for treating tobacco use and dependence: 2008 update. A U. S. Public Health Service report. Am J Prev Med. 2008;35(2):158-176.

5. Anthenelli RM. How–and why–to help psychiatric patients stop smoking. Current Psychiatry. 2005;4(1):77-87.

6. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database Syst Rev. 2007;1:CD000031.-

7. Williams JM, Foulds J. Successful tobacco dependence treatment in schizophrenia. Am J Psychiatry. 2007;164(2):222-227.

8. George TP, Vessicchio JC, Termine A, et al. A placebo controlled trial of bupropion for smoking cessation in schizophrenia. Biol Psychiatry. 2002;52(1):53-61.

9. Hughes JR, Kalman D. Do smokers with alcohol problems have more difficulty quitting? Drug Alcohol Depend. 2006;82(2):91-102.

10. McClure JB, Swan GE, Catz SL, et al. Smoking outcome by psychiatric history after behavioral and varenicline treatment. J Subst Abuse Treat. 2010;38(4):394-402.

11. Stapleton JA, Watson L, Spirling LI, et al. Varenicline in the routine treatment of tobacco dependence: a pre-post comparison with nicotine replacement therapy and an evaluation in those with mental illness. Addiction. 2008;103(1):146-154.

12. Hall SM, Muñoz RF, Reus VI. Cognitive-behavioral intervention increases abstinence rates for depressive-history smokers. J Consult Clin Psychol. 1994;62(1):141-146.

13. Hall SM, Muñoz RF, Reus VI, et al. Mood management and nicotine gum in smoking treatment: a therapeutic contact and placebo-controlled study. J Consult Clin Psychol. 1996;64(5):1003-1009.

14. Evins AE, Culhane MA, Alpert JE, et al. A controlled trial of bupropion added to nicotine patch and behavioral therapy for smoking cessation in adults with unipolar depressive disorders. J Clin Psychopharmacol. 2008;28(6):660-666.

15. Hall SM, Reus VI, Muñoz RF, et al. Nortriptyline and cognitive-behavioral therapy in the treatment of cigarette smoking. Arch Gen Psychiatry. 1998;55(8):683-690.

16. Brown RA, Kahler CW, Niaura R, et al. Cognitive-behavioral treatment for depression in smoking cessation. J Consult Clin Psychol. 2001;69(3):471-480.

17. McFall M, Saxon AJ, Malte CA, et al. Integrating tobacco cessation into mental health care for posttraumatic stress disorder: a randomized controlled trial. JAMA. 2010;304(22):2485-2493.

18. George TP, Ziedonis DM, Feingold A, et al. Nicotine transdermal patch and atypical antipsychotic medications for smoking cessation in schizophrenia. Am J Psychiatry. 2000;157(11):1835-1842.

19. Williams JM, Steinberg ML, Zimmermann MH, et al. Comparison of two intensities of tobacco dependence counseling in schizophrenia and schizoaffective disorder. J Subst Abuse Treat. 2010;38(4):384-393.

20. Evins AE, Cather C, Culhane MA, et al. A 12-week double-blind, placebo-controlled study of bupropion sr added to high-dose dual nicotine replacement therapy for smoking cessation or reduction in schizophrenia. J Clin Psychopharmacol. 2007;27(4):380-386.

21. Weinberger AH, Hitsman B, Papandonatos GD, et al. Predictors of abstinence and changes in psychiatric symptoms in a pooled sample of smokers with schizophrenia receiving combination pharmacotherapy and behavioral therapy for smoking cessation. J Clin Psychopharmacol. 2009;29(6):601-603.

22. Prochaska JJ, Hall SM, Tsoh JY, et al. Treating tobacco dependence in clinically depressed smokers: effect of smoking cessation on mental health functioning. Am J Public Health. 2008;98(3):446-448.

23. Tsoh JY, Humfleet GL, Muñoz RF, et al. Development of major depression after treatment for smoking cessation. Am J Psychiatry. 2000;157(3):368-374.

24. Prochaska JJ, Delucchi K, Hall SM. A meta-analysis of smoking cessation interventions with individuals in substance abuse treatment or recovery. J Consult Clin Psychol. 2004;72(6):1144-1156.

25. Zevin S, Benowitz NL. Drug interactions with tobacco smoking. An update. Clin Pharmacokinet. 1999;36(6):425-438.

Counseling. All smokers should be provided with brief interventions consistent with the 5 A’s—Ask, Advise, Assess, Assist, and Arrange (Table 2).⁴ For smokers who are not motivated to quit, the recommended approach follows the principles of the 5 R’s—Relevance, Risks, Rewards, Roadblocks, and Repetition (Table 3).⁴ Smokers who are motivated to quit and willing to participate in more intensive treatment may be offered face-to-face individual or group counseling (depending upon availability) or referred to a telephone quit line (see Related Resources). Intensive treatments such as these typically provide social support and assistance overcoming barriers to cessation and developing skills to initiate and maintain abstinence (eg, coping with a lapse or handling cravings, identifying and avoiding high-risk situations for smoking). As a general rule, greater intensity of counseling is associated with a greater likelihood of quitting.⁴

Table 2

The 5 A’s of tobacco treatment

	Intervention	Example
Ask	Systematically inquire about tobacco use	“Do you currently use, or have you ever used, tobacco products?”
Advise	Counsel all tobacco users to quit in a clear, strong, and personalized manner	“I think it is very important for you quit smoking to keep your breathing problems from getting any worse”
Assess	Determine the tobacco user’s willingness to make a quit attempt	“What do you think? Are you ready to quit?”
Assist	Offer or refer to treatment/support (if ready to quit; if not ready, see Table 3 for recommended interventions)	“I’m here to help you with this. Let me start by letting you know about the many options available to help you quit”
Arrange	Plan for follow-up contacts (at least 1, preferably within 1 week of the quit date)	“I would like to give you a call within the next week to see how you did with your quit date. Would that be OK with you?”
Source: Adapted from reference 4

Table 3

The 5 R’s: Principles of interventions for smokers not ready to quit

	Principle	Example
Relevance	Why is quitting smoking personally relevant?	“You’ve told me your kids sometimes make comments to you about quitting smoking. How does that affect you?”
Risks	What are the negative consequences of smoking?	“What don’t you like about smoking? What problems have you had from smoking?”
Rewards	What are the benefits of quitting smoking?	“Can you think of anything that would be good about quitting? Tell me about that”
Roadblocks	What are the barriers to quitting?	“What worries do you have about trying to quit? What happened the last time you tried to quit smoking?”
Repetition	Message repeated at every visit	“I know we have talked about quitting smoking before, but things may have changed since then. I also think that this is such an important issue we should keep it on the table for discussion. What do you think?”
Source: Adapted from reference 4

Q&A about treatment

How effective are smoking cessation interventions for individuals with psychiatric disorders? Several studies have demonstrated, on any given quit attempt, smokers with psychiatric or substance use disorders can be as successful as smokers without these disorders.^9-11 In fact, quit rates as high as approximately 70% for end-of-treatment¹¹ and 30% for 6-month follow-up¹⁰ have been reported. Of course, effectiveness varies by type and intensity of treatment as well as by individual characteristics of the smoker. Smokers with psychiatric disorders may fare better with more intensive interventions than briefer ones,^12,13 and factors such as high levels of nicotine dependence and exposure to smoking environments—both of which are characteristic of smokers with serious mental illness—can negatively impact treatment outcomes.⁴

Clinical Point

Some research suggests quitting smoking does not worsen symptoms of several common psychiatric disorders

Should the nature of the psychiatric disorder(s) guide decisions about the optimal pharmacotherapy or counseling approach? There have been numerous attempts to investigate the effectiveness of targeted interventions for particular subgroups of smokers with psychiatric disorders, including:

studies of the efficacy of the antidepressants bupropion¹⁴ and nortriptyline¹⁵ as well as cognitive-behavioral therapy-based mood management counseling¹⁶ for depressed smokers
integrative treatment approaches for smokers with posttraumatic stress disorder (PTSD)¹⁷
group counseling designed specifically for smokers with schizophrenia.^18,19

Although more research is needed and there have been some promising early results (eg, McFall et al¹⁷), current literature does not provide consistent evidence supporting treatment matching solely on the basis of the psychiatric disorder. Rather, patient preference, safety considerations (eg, use of medications in children/adolescents, pregnant women), medication side effect profiles, prior experience with the treatment approach, and cost/availability of treatment should guide development of the treatment plan. When results from placebo-controlled trials are available for subgroups of patients (eg, those with a history of major depression), consider this information when selecting a pharmacologic smoking cessation aid.

Clinical Point

Stopping smoking may increase serum levels of some medications, leading to increased side effects