Evidence-Based Reviews

How—and why—to help psychiatric patients stop smoking

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


 

References

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
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

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