Psychiatrists Urged to Help the Mentally Ill Stop Smoking

Janis Kelly

September 21, 2009

September 21, 2009 — People with mental illnesses smoke more than others, get less help from their physicians to stop smoking, and are at greater risk of dying from smoking-related disorders, new research shows.

"Over 75% of psychiatric patients smoke, and 50% are tobacco dependent. That will be what kills many of them," Tony P. George, MD, FRCPC, chair of addiction psychiatry, University of Toronto, Canada, told Medscape Psychiatry.

"Psychiatrists who think they can opt out of this problem are taking a risky stance. We are already seeing lawsuits brought by patients [and] by families of patients who died of smoking-related diseases, and by staff who have had to work in smoke-filled settings," he added.

Dr. George, who is also head of the Addictions Research and Concurrent Disorders Services Center for Addiction and Mental Health in Toronto, collaborated with Brian Hitsman, PhD, a tobacco addiction specialist and assistant professor of preventive medicine at Northwestern University Feinberg School of Medicine in Chicago, Illinois, to design the first comprehensive, evidence-based plan for psychiatrists and other mental health providers to help patients quit smoking.

Their article was published in the June issue of the Canadian Journal of Psychiatry.

High Percentage of Daily Smokers

The study shows that 40% to 80% of individuals with mental illness are daily smokers, depending on the disorder, compared with less than 20% of people without mental illness.

Nicotine dependence was defined as smoking the first cigarette of the day soon after awakening, smoking more frequently during the first hours of waking, finding the first cigarette of the day most satisfying, difficulty refraining from smoking in places where smoking is not permitted, heavy daily smoking, and smoking despite physical illness.

The mentally ill also tend to smoke more — often up to 2 packs per day. As a consequence, they have disproportionately high rates of tobacco-related diseases and mortality from cardiovascular diseases and cancer.

Dr. Hitsman found that the mentally ill receive tobacco treatment on only 12% of their visits to a psychiatrist and 38% of their visits to a primary care physician. One reason may be that many physicians, as well as many patients, assume that stopping smoking will worsen psychiatric symptoms, either as a result of the stress of smoking cessation or the absence of nicotine.

Dr. George said that review of studies done during the past 15 years shows not only that smoking cessation is safe for patients with mental illness, with little evidence of worsening psychiatric symptoms such as depression, but that depression and anxiety symptoms often decrease after the patient stops smoking. "The disrupted cognitive functioning that may occur is very short-term," he said.

Smoking Reduction a Poor Option

Although smoking reduction has attracted support as a useful alternative for patients who cannot, or do not, choose to quit smoking, Dr. George is not a fan. "Reduction of even 50% to 75% has never been proven to have any long-term benefits on things like cardiovascular disease, lung cancer, or chronic obstructive pulmonary disease," Dr. George said. "We really have to get these patients to quit smoking altogether."

Dr. George acknowledged that many patients who want to are unable to quit, and that quitting is likely to require repeated attempts. "We have to encourage them to keep trying. Tobacco dependence is a chronic disease, and like other chronic diseases it requires a long-term management plan. But our impact can be dramatic," Dr. George said. "Even having a physician give brief advice about doubles a patient's chance of quitting, and adding drug therapy quadruples that chance."

The researchers concluded that counseling approaches that include self-help programs, cognitive behavioral therapy, nicotine-replacement therapy and sustained-release bupropion (Zyban, GlaxoSmithKline) should be considered first-line smoking cessation therapy. Varenicline (Champix, Pfizer) is included in some guidelines as first-line medication but should be used with careful monitoring for neuropsychiatric symptoms, they write.

Dr. George says bupropion and varenicline, as well as second-line medications nortriptyline and clonidine, are best used with monitoring by a psychiatrist in patients with mental disorders. "I have seen some family physicians prescribe varenicline with disastrous consequences in these patients, but if you use these drugs with careful monitoring, you can get the same smoking cessation rates in schizophrenics as in the general population" he said.

Area of Neglect

According to Marc L. Steinberg, PhD, assistant professor of psychiatry at the Robert Wood Johnson Medical School, New Brunswick, New Jersey, told Medscape Psychiatry that one important avenue of research for smoking cessation that is being neglected are psychosocial treatments for this population.

The smoking cessation literature shows that for individuals with schizophrenia or schizoaffective disorder, there are currently no studies that disentangle the effects of tobacco dependence treatment medications from the effects of the psychosocial treatments.

"Determining how to best modify existing psychosocial treatments for this population is very important. While the medications are essential, psychosocial treatments should not be ignored," said Dr. Steinberg.

Dr. Steinberg, who has conducted research on motivating smokers with schizophrenia to seek treatment for smoking cessation, added that there is also a need to better understand how to motivate patients with psychiatric illnesses to stop smoking.

"Motivational interviewing has shown promise for increasing involvement in smoking cessation programs, but again, more research is necessary and more mental healthcare providers need to learn and implement these strategies," he said.

The research was supported by the National Institute on Drug Abuse, the National Alliance for Research on Schizophrenia and Depression, the Canadian Institutes of Health Research–Canadian Tobacco Control Research Initiative, the Canada Foundation for Innovation, the University of Toronto, and the Social Sciences and Humanities Research Council. Dr. George reports he has received grant support from Pfizer, Sepracor, Targacept, and Sanofi-Aventis and is a consultant to Pfizer, Prempharm, GlaxoSmithKline, Eli Lilly, Janssen-Ortho, and Evotec. Dr. Hitsman has consulted for Pinney Associates, subcontracted by GlaxoSmithKline.

Can J Psychiatry. 2009;54:368–378. Abstract


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