Evidence-Based Reviews

How—and why—to help psychiatric patients stop smoking

Current Psychiatry. 2005 January;4(1):77-87

Mentally-ill smokers can beat tobacco dependence with this brief clinical intervention

References

1. Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness: a population-based prevalence study. JAMA 2000;284(20):2606-10.

2. George TP, Vessicchio JC, Termine A. Nicotine and tobacco use in schizophrenia. In: Meyer JM, Nasrallah HR (eds). Medical illness and schizophrenia. Washington, DC: American Psychiatric Publishing, 2003:81-98.

3. Leonard S, Adler LE, Benhammou K, et al. Smoking and mental illness. Pharmacol Biochem Behav 2001;70(4):561-70.

4. Brown S, Inskip H, Barraclough B. Causes of the excess mortality of schizophrenia. Br J Psychiatry 2000;177:212-17.

5. American Psychiatric Association. Practice guideline for the treatment of patients with nicotine dependence. Am J Psychiatry 1996;53[153(suppl)]:1-31.

6. Himelhoch S, Daumit G. To whom do psychiatrists offer smoking-cessation counseling? Am J Psychiatry 2003;160(12):2228-30.

7. Thorndike AN, Stafford RS, Rigotti NA. US physicians’ treatment of smoking in outpatients with psychiatric diagnoses. Nicotine Tob Res 2001;3(1):85-91.

8. Lin SW, Anthenelli RM. Genetic factors in the risk for substance use disorders. In: Lowinson J, Ruiz P, Millman RB, Langrod JC (eds). Substance abuse: a comprehensive textbook (4th ed). Philadelphia: Lippincott Williams and Wilkins, 2004.

9. Tyndale RF, Sellers EM. Genetic variation in CYP2A6-mediated nicotine metabolism alters smoking behavior. Ther Drug Monit 2002;24(1):163-71.

10. Newhouse P, Singh A, Potter A. Nicotine and nicotinic receptor involvement in neuropsychiatric disorders. Curr Top Med Chem 2004;4(3):267-82.

11. McEvoy JP, Allen TB. The importance of nicotinic acetylcholine receptors in schizophrenia, bipolar disorder and Tourette’s syndrome. Curr Drug Target CNS Neurol Disord 2002;1(4):433-42.

12. Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence. Clinical practice guideline. U.S. Public Health Service. Rockville, MD: Department of Health and Human Services, 2000. Available at http:www.ahcpr.gov/path/tobacco.htm.

13. Covey LS, Glassman AH, Stetner F. Cigarette smoking and major depression. J Addict Disord 1998;17(1):35-46.

14. Berlin I, Anthenelli RM. Monoamine oxidases and tobacco smoking. Intl J Neuropsychopharmacol 2001;4(1):33-42.

15. Killen JD, Fortmann SP, Schatzberg A, et al. Onset of major depression during treatment for nicotine dependence. Addict Behav 2003;28(3):461-70.

16. Breslau N. Psychiatric comorbidity of smoking and nicotine dependence. Behav Genet 1995;25:95-101.

17. Addington J, el Guebaly N, Campbell W, et al. Smoking cessation treatment for patients with schizophrenia. Am J Psychiatry 1998;155(7):974-6.

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):1835-42.

19. Lemon SC, Friedmann PD, Stein MD. The impact of smoking cessation on drug abuse treatment outcome. Addict Behav 2003;28(7):1323-31.

20. Prior TI, Baker GB. Interactions between the cytochrome P450 system and the second-generation antipsychotics. J Psychiatry Neurosci 2003;28(2):99-112.

21. Rogotti NA. Clinical practice: treatment of tobacco use and dependence. N Engl J Med 2002;346(7):506-12.

22. Ziedonis D, Williams JM, Smelson D. Serious mental illness and tobacco addiction: a model program to address this common but neglected issue. Am J Med Sci 2003;326(4):223-30.

Three myths about cigarette smoking may explain why psychiatrists rarely intervene in their patients’ tobacco dependence:

Cigarette smoking is an incurable habit in psychiatric patients and thus not worth the effort of intervening.
Cigarette smoking is an acceptable form of self-medication in persons with psychiatric illness.
Quitting smoking will worsen psychiatric symptoms.

Smoking by psychiatric patients is treatable, however, and evidence proves that many can quit.¹ This article rebuts the “why-bother?” myths and provides practical tips on how to more effectively help psychiatric patients stop smoking.

DEBUNKING THREE MYTHS

Mentally ill women and men consume nearly one-half (44%) of the cigarettes smoked in the United States (Table 1)^1-3 and thus are at high risk for tobacco-related premature death, cancer, cardiovascular disease, and respiratory disorders. Although recognized as a leading cause of death, cigarette smoking by psychiatric patients frequently goes unaddressed, contributing to excess mortality in this population.⁴

Table 1

Cigarette smoking: An epidemic among psychiatric patients

Adults with mental illness are at least twice as likely to smoke as are adults without mental illness Smoking rates in the seriously mentally ill (with schizophrenia or bipolar disorder) are estimated at 45% to 75% The greater the number of an individual’s psychiatric diagnoses, the greater the likelihood that he or she is a cigarette smoker Mentally ill patients are more likely to be heavy smokers (≥20 cigarettes/day) than are smokers without mental illness
Source: References 1-3

Adults with mental illness are at least twice as likely to smoke as are adults without mental illness
Smoking rates in the seriously mentally ill (with schizophrenia or bipolar disorder) are estimated at 45% to 75%
The greater the number of an individual’s psychiatric diagnoses, the greater the likelihood that he or she is a cigarette smoker
Mentally ill patients are more likely to be heavy smokers (≥20 cigarettes/day) than are smokers without mental illness

Source: References 1-3

American Psychiatric Association (APA) guidelines recommend routine smoking cessation treatment,⁵ but two studies of data from the National Ambulatory Medical Care Survey found that:

psychiatrists seldom (6,7
when counseling did occur, nicotine replacement therapy was not prescribed.⁶

Is smoking ‘incurable’? In the large-scale National Comorbidity Survey, one-third of smokers with a history of psychiatric illness reported they quit smoking, compared with 42% of smokers without psychiatric illness. Short-term abstinence rates as high as 35% have been reported among even the most difficult-to-treat, seriously mentally-ill smokers when they receive combined smoking cessation drug therapy and counseling.²

Tobacco dependence is a syndrome with strong genetic and biologic roots. Family, twin, and adoption studies show consistently that tobacco dependence is genetically mediated.⁸ Genetic polymorphisms are being identified that may modify an individual’s risk for developing nicotine dependence—such as the gene encoding the cytochrome P-450 2A6 isoenzyme (CYP 2A6) that metabolizes nicotine to cotinine.⁹ Disturbed nicotinic receptor functioning has been shown in persons with schizophrenia, mood disorders, anxiety disorders, and attention-deficit/hyperactivity disorders.^3,10,11

Tobacco dependence is a chronic, relapsing condition that usually requires repeated intervention to motivate patients to try to quit and to help those who are willing to quit to succeed. Effective smoking cessation aids include:

behavioral therapy (brief physician advice, problem-solving skills/skills training)
pharmacologic therapy (nicotine replacement, sustained-release bupropion).¹²

Many aids have been tested in mentally ill smokers with some success. The nicotine transdermal patch, for example, has been shown to help with smoking reduction and cessation in smokers with schizophrenia.²

Is smoking ‘self-medication’? Compelling evidence indicates that cholinergic mechanisms and nicotinic receptors (nAChRs) are involved in the pathophysiology of schizophrenia and other neuropsychiatric disorders.^3,10 Nicotine administration appears to improve sensory-processing and cognitive deficits observed in schizophrenia.^2,3 Moreover, the association between depression and smoking¹³ —and tobacco smoke’s monoamine oxidase-inhibiting and other psychoactive properties¹⁴ —have led some to posit that cigarette smoking may have antidepressant actions.¹⁰

For all these reasons, some authors have speculated that tobacco use may be a form of self-medication among the psychiatrically ill.³ The problem with this hypothesis, however, is that tobacco smoke is—at best—an untested and potentially lethal cognitive enhancer, antidepressant, or anxiolytic. Animal and human studies may find therapeutic effects of acute nicotine administration, but the cognitive effects of chronic tobacco smoking are not known.

Table 2

5 ‘A’s of brief clinical intervention for tobacco dependence

Ask about tobacco use Advise the patient to quit Assess the patient’s willingness to make a quit effort Assist the patient in his effort to quit Arrange follow-up for the quit attempt
Source: References 5 and 12

Furthermore, because nicotine is one of tobacco smoke’s more than 4,000 chemical compounds—many of which are toxic or carcinogenic—linking “tobacco smoke” and “medication” in the same sentence seems imprudent. Instead, even if tobacco smoking initially may ameliorate some psychiatric symptoms in our patients, it’s a lousy medication, and much safer alternatives are available.

Adverse effects from quitting? Smokers with a history of major depressive disorder have been shown to be at risk to:

develop another depressive episode after they quit smoking¹⁵
experience more severe withdrawal symptoms during abstinence, compared with smokers with no history of depression.^13,16