How—and why—to help psychiatric patients stop smoking

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
  

 

Scant data support the myth that smoking cessation worsens psychiatric symptoms. For example, in a review on tobacco dependence and schizophrenia, George et al² concluded that the effects of smoking cessation on schizophrenia symptoms are not clear. Two smoking cessation trials in schizophrenic patients treated with nicotine patches found no significant changes in postcessation psychotic symptoms.^17,18

Concerns that substance-abusing patients should not attempt to quit smoking during alcohol and other drug dependence treatment are also unsubstantiated. Rather than exacerbating drug addiction, smoking cessation has been found to improve addicts’ abstinence rates.¹⁹

USING AVAILABLE THERAPIES

Evidence is insufficient so far to show whether psychiatrically ill smokers would benefit more from specially tailored cessation treatments than from standard treatments, according to the 2000 U.S. Public Health Service clinical practice guide.¹² Thus, while researchers try to resolve this issue, psychiatrists are left to use medications found to be effective in smokers overall.

Clinical vignette. Mr. J, age 45, has paranoid-type schizophrenia and has been smoking at least two packs of cigarettes daily for 25 years. He complains of a productive cough and expresses interest in quitting smoking when his psychiatrist raises this topic.

His persecutory delusions are well-controlled on olanzapine, 10 mg/d. He is adhering with his medications and participating in weekly group counseling that provides supportive therapy for patients with serious mental illness.

In this schizophrenic smoker who is willing to try to quit, the psychiatrist performed the first three of “5 ‘A’s” (Table 2) of brief clinical intervention for tobacco dependence.^5,12 The next steps are to assist the patient’s effort to quit and arrange follow-up.

When to quit. The best time for a smoker with psychiatric illness to try to quit is when he or she:

• is psychiatrically stable
  
• is not in crisis
  
• has no recent or planned psychiatric drug changes.
  

Table 3

Smoking cessation may increase blood levels of these psychotropics

Antipsychotics	Antidepressants	Mood stabilizers	Anxiolytics
Haloperidol	Clomipramine	Carbamazepine	Desmethyldiazepam
Chlorpromazine	Desipramine		Oxazepam
Fluphenazine	Doxepin
Olanzapine	Imipramine
Clozapine	Nortriptyline
Source: References 2, 5, and 20

Monitoring for side effects. Because cigarette smoking can induce the CYP 1A2 isoenzyme system, abstinence can increase many psychotropics’ blood levels (Table 3).^2,5,20 Therefore, the clinician needs to monitor the actions and possible side effects of Mr. J’s medications should he reduce or quit smoking.

Olanzapine’s clearance is approximately 40% higher in smokers than in nonsmokers. The psychiatrist discussed this with Mr. J and:

• asked him to call if side effects develop during the quit attempt
  
• scheduled more-frequent appointments to monitor side effects.
  

Choosing medication. First-line drugs for smoking cessation include sustained-release bupropion and nicotine replacement therapy (NRT). Clonidine, nortriptyline, and combination NRT are second-line¹² (Table 4).²¹ For more information on treating patients with nicotine dependence, refer to APA practice guidelines (see Related resources).

Mr. J’s schizophrenia is stable on maintenance therapy with an atypical antipsychotic. Schizophrenic smokers taking atypicals may be more able to quit smoking with NRT or sustained-release bupropion, compared with those taking conventional antipsychotics.²

The psychiatrist also determined that Mr. J had tried to quit smoking three times. Two of these attempts were done “cold turkey,” without pharmacotherapy, and one involved using nicotine gum. Mr. J said that although the gum “worked well at first,” he stopped using it because it was expensive and made his mouth sore. This information helped the psychiatrist choose medication for this quit attempt.

Most smoking cessation guidelines rely on a stepped-care approach, progressing from minimal to more-intensive interventions as needed.⁵ Mr. J’s psychiatrist devised an intensive treatment plan because:

• Mr. J has tried to quit before
  
• schizophrenic patients generally have more difficulty quitting and are more nicotine-dependent than other smokers.
  

Choosing a quit date. Mr. J will receive both pharmacotherapy and counseling, which may be more effective than either treatment alone.²² The psychiatrist and Mr. J agree on a target quit date (TQD), chosen to coincide with when he can attend a smoking cessation behavioral program at a community mental health agency^18,22 and attend weekly follow-up visits, scheduled in advance.

Table 4

Nicotine replacement and other options for smoking cessation

Drug	Daily dosage	Treatment duration*	Common side effects
Nicotine replacement therapy†
Transdermal			Skin irritation, insomnia
24-hr patch	Starting dose is 21 mg/d; also in 7- and 14-mg patches for tapering dosage	8 wk
16-hr patch	15 mg	8 wk
Polacrilex (gum) 2- or 4-mg piece	1 piece/hr (	8 to 12 wk	Mouth irritation, sore jaw, dyspepsia, hiccups
Vapor inhaler	6 to 16 cartridges/day (delivers 4/mg/cartridge)	3 to 6 mo	Mouth and throat irritation, cough
Nasal spray	1 to 2 doses/hr; dose = 1 mg (0.5 mg per nostril); maximum dosage 40 mg/d	3 to 6 mo	Nasal irritation, sneezing, cough, tearing eyes
Lozenge	2- or 4-mg dose; see dosage formula, titration schedule in over-the-counter package	12 wk	Hiccups, nausea, heartburn
Non-nicotine replacement therapy
Sustained-release bupropion†	150 mg/d for 3 days, then 150 mg bid; start 1 week before quit date	7 to 12 wk; up to 6 mo. to maintain abstinence	Insomnia, dry mouth, agitation
Nortriptyline	75 to 100 mg/d; start 10 to 28 days before quit date at 25 mg/d and increase as tolerated	12 wk	Dry mouth, sedation, dizziness
Clonidine	0.1 to 0.3 mg bid	3 to 10 wk	Dry mouth, sedation, dizziness
* Treatment duration varies and may be longer in patients with psychiatric disorders.
† FDA-approved as a smoking cessation aid and recommended as a first-line drug by Public Health Service clinical guidelines.
Source: Adapted from reference 21.

 

On the morning of his TQD, Mr. J is to apply the first 21-mg transdermal nicotine patch. He is told not to smoke that day and to apply a new patch daily. The psychiatrist also tells him he will most likely remain on that dosage for 4 weeks. Then the patch strength will be reduced in 7-mg aliquots every 2 to 4 weeks, depending on his progress. The psychiatrist also provides him with educational materials on how to quit successfully.

Follow-up. Recognizing that most relapses occur in the first few days of quitting, the psychiatrist sets Mr. J’s first follow-up appointment for the day after his TQD to assess:

• whether he has smoked and number of cigarettes smoked per day
  
• presence and severity of withdrawal symptoms
  
• onset of psychiatric symptoms
  
• treatment adherence
  
• how he is handling high-risk situations and urges to smoke
  
• medication side effects.⁶
  

Another follow-up visit is set for 1 week later, and weekly telephone appointments are scheduled for the rest of the month, with a face-to-face appointment set 1 month after his quit date.

Related resources

• American Psychiatric Association. Practice guideline for the treatment of patients with nicotine dependence. Am J Psychiatry 1996; 53(153[suppl]): 1-31.
  
• Fiore MC, Bailey WC, Cohen SJ, et.al. Treating tobacco use and dependence. Clinical practice guideline. Rockville, MD: U.S. Public Health Service, 2000. http://www.ahcpr.gov/path/tobacco.htm. Accessed Dec. 13, 2004.
  

Drug brand names

• Amantadine • Symmetrel
  
• Bupropion • Wellbutrin SR, Zyban
  
• Clonidine • Catapres
  
• Nicotine nasal spray • Nicotrol NS
  
• Nicotine polacrilex • Nicorette
  
• Nicotine replacement patch • Nicoderm CQ, Nicotrol, others
  
• Nicotine vapor inhaler • Nicotrol Inhaler
  
• Nortriptyline •Aventyl, Pamelor
  

Disclosure

Dr. Anthenelli receives grant/research support from Sanofi-Aventis and Ortho-McNeil Pharmaceuticals and is a consultant and speaker for Sanofi-Aventis.

Acknowledgments

The author would like to thank Reene Cantwell for technical assistance in preparing this manuscript. This work was supported by grants R01 AA13307 and R01 AA13957 from the National Institute on Alcohol Abuse and Alcoholism and by the Department of Veterans Affairs.

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
  

 

Scant data support the myth that smoking cessation worsens psychiatric symptoms. For example, in a review on tobacco dependence and schizophrenia, George et al² concluded that the effects of smoking cessation on schizophrenia symptoms are not clear. Two smoking cessation trials in schizophrenic patients treated with nicotine patches found no significant changes in postcessation psychotic symptoms.^17,18

Concerns that substance-abusing patients should not attempt to quit smoking during alcohol and other drug dependence treatment are also unsubstantiated. Rather than exacerbating drug addiction, smoking cessation has been found to improve addicts’ abstinence rates.¹⁹

USING AVAILABLE THERAPIES

Evidence is insufficient so far to show whether psychiatrically ill smokers would benefit more from specially tailored cessation treatments than from standard treatments, according to the 2000 U.S. Public Health Service clinical practice guide.¹² Thus, while researchers try to resolve this issue, psychiatrists are left to use medications found to be effective in smokers overall.

Clinical vignette. Mr. J, age 45, has paranoid-type schizophrenia and has been smoking at least two packs of cigarettes daily for 25 years. He complains of a productive cough and expresses interest in quitting smoking when his psychiatrist raises this topic.

His persecutory delusions are well-controlled on olanzapine, 10 mg/d. He is adhering with his medications and participating in weekly group counseling that provides supportive therapy for patients with serious mental illness.

In this schizophrenic smoker who is willing to try to quit, the psychiatrist performed the first three of “5 ‘A’s” (Table 2) of brief clinical intervention for tobacco dependence.^5,12 The next steps are to assist the patient’s effort to quit and arrange follow-up.

When to quit. The best time for a smoker with psychiatric illness to try to quit is when he or she:

• is psychiatrically stable
  
• is not in crisis
  
• has no recent or planned psychiatric drug changes.
  

Table 3

Smoking cessation may increase blood levels of these psychotropics

Antipsychotics	Antidepressants	Mood stabilizers	Anxiolytics
Haloperidol	Clomipramine	Carbamazepine	Desmethyldiazepam
Chlorpromazine	Desipramine		Oxazepam
Fluphenazine	Doxepin
Olanzapine	Imipramine
Clozapine	Nortriptyline
Source: References 2, 5, and 20

Monitoring for side effects. Because cigarette smoking can induce the CYP 1A2 isoenzyme system, abstinence can increase many psychotropics’ blood levels (Table 3).^2,5,20 Therefore, the clinician needs to monitor the actions and possible side effects of Mr. J’s medications should he reduce or quit smoking.

Olanzapine’s clearance is approximately 40% higher in smokers than in nonsmokers. The psychiatrist discussed this with Mr. J and:

• asked him to call if side effects develop during the quit attempt
  
• scheduled more-frequent appointments to monitor side effects.
  

Choosing medication. First-line drugs for smoking cessation include sustained-release bupropion and nicotine replacement therapy (NRT). Clonidine, nortriptyline, and combination NRT are second-line¹² (Table 4).²¹ For more information on treating patients with nicotine dependence, refer to APA practice guidelines (see Related resources).

Mr. J’s schizophrenia is stable on maintenance therapy with an atypical antipsychotic. Schizophrenic smokers taking atypicals may be more able to quit smoking with NRT or sustained-release bupropion, compared with those taking conventional antipsychotics.²

The psychiatrist also determined that Mr. J had tried to quit smoking three times. Two of these attempts were done “cold turkey,” without pharmacotherapy, and one involved using nicotine gum. Mr. J said that although the gum “worked well at first,” he stopped using it because it was expensive and made his mouth sore. This information helped the psychiatrist choose medication for this quit attempt.

Most smoking cessation guidelines rely on a stepped-care approach, progressing from minimal to more-intensive interventions as needed.⁵ Mr. J’s psychiatrist devised an intensive treatment plan because:

• Mr. J has tried to quit before
  
• schizophrenic patients generally have more difficulty quitting and are more nicotine-dependent than other smokers.
  

Choosing a quit date. Mr. J will receive both pharmacotherapy and counseling, which may be more effective than either treatment alone.²² The psychiatrist and Mr. J agree on a target quit date (TQD), chosen to coincide with when he can attend a smoking cessation behavioral program at a community mental health agency^18,22 and attend weekly follow-up visits, scheduled in advance.

Table 4

Nicotine replacement and other options for smoking cessation

Drug	Daily dosage	Treatment duration*	Common side effects
Nicotine replacement therapy†
Transdermal			Skin irritation, insomnia
24-hr patch	Starting dose is 21 mg/d; also in 7- and 14-mg patches for tapering dosage	8 wk
16-hr patch	15 mg	8 wk
Polacrilex (gum) 2- or 4-mg piece	1 piece/hr (	8 to 12 wk	Mouth irritation, sore jaw, dyspepsia, hiccups
Vapor inhaler	6 to 16 cartridges/day (delivers 4/mg/cartridge)	3 to 6 mo	Mouth and throat irritation, cough
Nasal spray	1 to 2 doses/hr; dose = 1 mg (0.5 mg per nostril); maximum dosage 40 mg/d	3 to 6 mo	Nasal irritation, sneezing, cough, tearing eyes
Lozenge	2- or 4-mg dose; see dosage formula, titration schedule in over-the-counter package	12 wk	Hiccups, nausea, heartburn
Non-nicotine replacement therapy
Sustained-release bupropion†	150 mg/d for 3 days, then 150 mg bid; start 1 week before quit date	7 to 12 wk; up to 6 mo. to maintain abstinence	Insomnia, dry mouth, agitation
Nortriptyline	75 to 100 mg/d; start 10 to 28 days before quit date at 25 mg/d and increase as tolerated	12 wk	Dry mouth, sedation, dizziness
Clonidine	0.1 to 0.3 mg bid	3 to 10 wk	Dry mouth, sedation, dizziness
* Treatment duration varies and may be longer in patients with psychiatric disorders.
† FDA-approved as a smoking cessation aid and recommended as a first-line drug by Public Health Service clinical guidelines.
Source: Adapted from reference 21.

 

On the morning of his TQD, Mr. J is to apply the first 21-mg transdermal nicotine patch. He is told not to smoke that day and to apply a new patch daily. The psychiatrist also tells him he will most likely remain on that dosage for 4 weeks. Then the patch strength will be reduced in 7-mg aliquots every 2 to 4 weeks, depending on his progress. The psychiatrist also provides him with educational materials on how to quit successfully.

Follow-up. Recognizing that most relapses occur in the first few days of quitting, the psychiatrist sets Mr. J’s first follow-up appointment for the day after his TQD to assess:

• whether he has smoked and number of cigarettes smoked per day
  
• presence and severity of withdrawal symptoms
  
• onset of psychiatric symptoms
  
• treatment adherence
  
• how he is handling high-risk situations and urges to smoke
  
• medication side effects.⁶
  

Another follow-up visit is set for 1 week later, and weekly telephone appointments are scheduled for the rest of the month, with a face-to-face appointment set 1 month after his quit date.

Related resources

• American Psychiatric Association. Practice guideline for the treatment of patients with nicotine dependence. Am J Psychiatry 1996; 53(153[suppl]): 1-31.
  
• Fiore MC, Bailey WC, Cohen SJ, et.al. Treating tobacco use and dependence. Clinical practice guideline. Rockville, MD: U.S. Public Health Service, 2000. http://www.ahcpr.gov/path/tobacco.htm. Accessed Dec. 13, 2004.
  

Drug brand names

• Amantadine • Symmetrel
  
• Bupropion • Wellbutrin SR, Zyban
  
• Clonidine • Catapres
  
• Nicotine nasal spray • Nicotrol NS
  
• Nicotine polacrilex • Nicorette
  
• Nicotine replacement patch • Nicoderm CQ, Nicotrol, others
  
• Nicotine vapor inhaler • Nicotrol Inhaler
  
• Nortriptyline •Aventyl, Pamelor
  

Disclosure

Dr. Anthenelli receives grant/research support from Sanofi-Aventis and Ortho-McNeil Pharmaceuticals and is a consultant and speaker for Sanofi-Aventis.

Acknowledgments

The author would like to thank Reene Cantwell for technical assistance in preparing this manuscript. This work was supported by grants R01 AA13307 and R01 AA13957 from the National Institute on Alcohol Abuse and Alcoholism and by the Department of Veterans Affairs.

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
  

 

Scant data support the myth that smoking cessation worsens psychiatric symptoms. For example, in a review on tobacco dependence and schizophrenia, George et al² concluded that the effects of smoking cessation on schizophrenia symptoms are not clear. Two smoking cessation trials in schizophrenic patients treated with nicotine patches found no significant changes in postcessation psychotic symptoms.^17,18

Concerns that substance-abusing patients should not attempt to quit smoking during alcohol and other drug dependence treatment are also unsubstantiated. Rather than exacerbating drug addiction, smoking cessation has been found to improve addicts’ abstinence rates.¹⁹

USING AVAILABLE THERAPIES

Evidence is insufficient so far to show whether psychiatrically ill smokers would benefit more from specially tailored cessation treatments than from standard treatments, according to the 2000 U.S. Public Health Service clinical practice guide.¹² Thus, while researchers try to resolve this issue, psychiatrists are left to use medications found to be effective in smokers overall.

Clinical vignette. Mr. J, age 45, has paranoid-type schizophrenia and has been smoking at least two packs of cigarettes daily for 25 years. He complains of a productive cough and expresses interest in quitting smoking when his psychiatrist raises this topic.

His persecutory delusions are well-controlled on olanzapine, 10 mg/d. He is adhering with his medications and participating in weekly group counseling that provides supportive therapy for patients with serious mental illness.

In this schizophrenic smoker who is willing to try to quit, the psychiatrist performed the first three of “5 ‘A’s” (Table 2) of brief clinical intervention for tobacco dependence.^5,12 The next steps are to assist the patient’s effort to quit and arrange follow-up.

When to quit. The best time for a smoker with psychiatric illness to try to quit is when he or she:

• is psychiatrically stable
  
• is not in crisis
  
• has no recent or planned psychiatric drug changes.
  

Table 3

Smoking cessation may increase blood levels of these psychotropics

Antipsychotics	Antidepressants	Mood stabilizers	Anxiolytics
Haloperidol	Clomipramine	Carbamazepine	Desmethyldiazepam
Chlorpromazine	Desipramine		Oxazepam
Fluphenazine	Doxepin
Olanzapine	Imipramine
Clozapine	Nortriptyline
Source: References 2, 5, and 20

Monitoring for side effects. Because cigarette smoking can induce the CYP 1A2 isoenzyme system, abstinence can increase many psychotropics’ blood levels (Table 3).^2,5,20 Therefore, the clinician needs to monitor the actions and possible side effects of Mr. J’s medications should he reduce or quit smoking.

Olanzapine’s clearance is approximately 40% higher in smokers than in nonsmokers. The psychiatrist discussed this with Mr. J and:

• asked him to call if side effects develop during the quit attempt
  
• scheduled more-frequent appointments to monitor side effects.
  

Choosing medication. First-line drugs for smoking cessation include sustained-release bupropion and nicotine replacement therapy (NRT). Clonidine, nortriptyline, and combination NRT are second-line¹² (Table 4).²¹ For more information on treating patients with nicotine dependence, refer to APA practice guidelines (see Related resources).

Mr. J’s schizophrenia is stable on maintenance therapy with an atypical antipsychotic. Schizophrenic smokers taking atypicals may be more able to quit smoking with NRT or sustained-release bupropion, compared with those taking conventional antipsychotics.²

The psychiatrist also determined that Mr. J had tried to quit smoking three times. Two of these attempts were done “cold turkey,” without pharmacotherapy, and one involved using nicotine gum. Mr. J said that although the gum “worked well at first,” he stopped using it because it was expensive and made his mouth sore. This information helped the psychiatrist choose medication for this quit attempt.

Most smoking cessation guidelines rely on a stepped-care approach, progressing from minimal to more-intensive interventions as needed.⁵ Mr. J’s psychiatrist devised an intensive treatment plan because:

• Mr. J has tried to quit before
  
• schizophrenic patients generally have more difficulty quitting and are more nicotine-dependent than other smokers.
  

Choosing a quit date. Mr. J will receive both pharmacotherapy and counseling, which may be more effective than either treatment alone.²² The psychiatrist and Mr. J agree on a target quit date (TQD), chosen to coincide with when he can attend a smoking cessation behavioral program at a community mental health agency^18,22 and attend weekly follow-up visits, scheduled in advance.

Table 4

Nicotine replacement and other options for smoking cessation

Drug	Daily dosage	Treatment duration*	Common side effects
Nicotine replacement therapy†
Transdermal			Skin irritation, insomnia
24-hr patch	Starting dose is 21 mg/d; also in 7- and 14-mg patches for tapering dosage	8 wk
16-hr patch	15 mg	8 wk
Polacrilex (gum) 2- or 4-mg piece	1 piece/hr (	8 to 12 wk	Mouth irritation, sore jaw, dyspepsia, hiccups
Vapor inhaler	6 to 16 cartridges/day (delivers 4/mg/cartridge)	3 to 6 mo	Mouth and throat irritation, cough
Nasal spray	1 to 2 doses/hr; dose = 1 mg (0.5 mg per nostril); maximum dosage 40 mg/d	3 to 6 mo	Nasal irritation, sneezing, cough, tearing eyes
Lozenge	2- or 4-mg dose; see dosage formula, titration schedule in over-the-counter package	12 wk	Hiccups, nausea, heartburn
Non-nicotine replacement therapy
Sustained-release bupropion†	150 mg/d for 3 days, then 150 mg bid; start 1 week before quit date	7 to 12 wk; up to 6 mo. to maintain abstinence	Insomnia, dry mouth, agitation
Nortriptyline	75 to 100 mg/d; start 10 to 28 days before quit date at 25 mg/d and increase as tolerated	12 wk	Dry mouth, sedation, dizziness
Clonidine	0.1 to 0.3 mg bid	3 to 10 wk	Dry mouth, sedation, dizziness
* Treatment duration varies and may be longer in patients with psychiatric disorders.
† FDA-approved as a smoking cessation aid and recommended as a first-line drug by Public Health Service clinical guidelines.
Source: Adapted from reference 21.

 

On the morning of his TQD, Mr. J is to apply the first 21-mg transdermal nicotine patch. He is told not to smoke that day and to apply a new patch daily. The psychiatrist also tells him he will most likely remain on that dosage for 4 weeks. Then the patch strength will be reduced in 7-mg aliquots every 2 to 4 weeks, depending on his progress. The psychiatrist also provides him with educational materials on how to quit successfully.

Follow-up. Recognizing that most relapses occur in the first few days of quitting, the psychiatrist sets Mr. J’s first follow-up appointment for the day after his TQD to assess:

• whether he has smoked and number of cigarettes smoked per day
  
• presence and severity of withdrawal symptoms
  
• onset of psychiatric symptoms
  
• treatment adherence
  
• how he is handling high-risk situations and urges to smoke
  
• medication side effects.⁶
  

Another follow-up visit is set for 1 week later, and weekly telephone appointments are scheduled for the rest of the month, with a face-to-face appointment set 1 month after his quit date.

Related resources

• American Psychiatric Association. Practice guideline for the treatment of patients with nicotine dependence. Am J Psychiatry 1996; 53(153[suppl]): 1-31.
  
• Fiore MC, Bailey WC, Cohen SJ, et.al. Treating tobacco use and dependence. Clinical practice guideline. Rockville, MD: U.S. Public Health Service, 2000. http://www.ahcpr.gov/path/tobacco.htm. Accessed Dec. 13, 2004.
  

Drug brand names

• Amantadine • Symmetrel
  
• Bupropion • Wellbutrin SR, Zyban
  
• Clonidine • Catapres
  
• Nicotine nasal spray • Nicotrol NS
  
• Nicotine polacrilex • Nicorette
  
• Nicotine replacement patch • Nicoderm CQ, Nicotrol, others
  
• Nicotine vapor inhaler • Nicotrol Inhaler
  
• Nortriptyline •Aventyl, Pamelor
  

Disclosure

Dr. Anthenelli receives grant/research support from Sanofi-Aventis and Ortho-McNeil Pharmaceuticals and is a consultant and speaker for Sanofi-Aventis.

Acknowledgments

The author would like to thank Reene Cantwell for technical assistance in preparing this manuscript. This work was supported by grants R01 AA13307 and R01 AA13957 from the National Institute on Alcohol Abuse and Alcoholism and by the Department of Veterans Affairs.