Cessation Program Works for Smokers With SUD, Mental Illness

Deborah Brauser

December 23, 2014

AVENTURA, Florida ― An integrated tobacco treatment intervention may decrease not only cigarette smoking but also cannabis and alcohol use in patients with co-occurring serious mental illness (SMI) and substance use disorder (SUD), new research suggests.

A randomized controlled trial of 216 long-term smokers who also had an SMI and an SUD showed that 22% of those who received the tobacco intervention, which combined counseling with nicotine replacement therapy (NRP) and a stage-focused computerized program, were abstinent from tobacco 1 year later vs 11% of their matched peers who received care as usual.

Interestingly, those who quit smoking were also less likely to use cannabis and alcohol 1 year posttreatment than were those who did not quit smoking.

Their findings suggest that tobacco treatment can be effective in this patient population, lead author Smita Das, MD, PhD, MPH, told meeting delegates here at the American Academy of Addiction Psychiatry (AAAP) 25th Annual Meeting.

"We can be a little less afraid, based on this analysis, of it worsening other substance use disorders," said Dr Das, who is from Stanford University School of Medicine, California. "In addition, stage-tailored interventions meet patients at their level, which can lead to less resistance and better outcomes."

Compromised Recovery?

The investigators note that although smoking is prevalent in individuals with psychiatric disorders, cessation is often discouraged in those with comorbid SUD. "A barrier to treatment has been concerns that quitting smoking may compromise recovery," they write.

Dr Das reported that individuals with mental illness and/or an SUD consume 44% to 46% of all cigarettes sold in the United States and that adults with SMI, on average, die 25 years earlier than the general population from treatable conditions related to tobacco use.

"Smoking accounts for more morbidity than all other drugs and alcohol combined, even among individuals with SUD. Nicotine is a very heavy hitter," she said.

Although clinical practice guidelines and the American Psychiatric Association recommend providing evidence-based tobacco cessation treatment to all smokers, "as clinicians, we can often be squeamish about doing that," said Dr Das.

In fact, she reported that a 2007 American Association of Medical Colleges survey of more than 3000 clinicians showed that psychiatrists were reluctant to address tobacco concerns, with 47% saying that patients have more immediate problems to deal with.

"People will say, 'They have all these other things to worry about, let them have their tobacco.' They also worry that patients' anxiety or depression will worsen if we try to take away tobacco," she said.

"However, I'd argue that we should put that squeamishness aside and try to treat tobacco, because the outcomes can be positive. Also, patients tend to be interested in quitting."

She added that emerging evidence is showing that clinical symptoms of unipolar depression, bipolar disorder, posttraumatic stress disorder, and schizophrenia do not worsen after tobacco cessation treatment.

The current study included 216 adults (66% men) who were hospitalized in locked psychiatry units in the San Francisco Bay Area. The facilities were 100% smoke-free.

At baseline, the participants met clinical criteria for an SUD, as measured by a score of 8 or higher on the Alcohol Use Disorders Identification Test (AUDIT) and/or a score of 3 or higher on the Drug Abuse Screening Test (DAST). They also smoked a mean of 19 cigarettes per day.

In addition, 44% of the participants had unipolar depression, 24% had general psychosis, 20% had bipolar disorder, and 12% had other SMI.

Higher Quit Rate

All patients were randomly assigned to receive either the intervention (n = 105; 62% men; mean age, 38 years) or usual care (n = 111; 69% men; mean age, 40 years). The intervention included a 15- to 30-minute counseling session, a "stage-tailored expert system" at baseline, a stage-tailored manual, and 10 weeks of nicotine patch NRT post hospitalization.

"What was great about this was that there weren't limitations on what stage people were in. Some could be in preparation stage and ready to quit [20%], or in contemplation [50%] or precontemplation [30%] stage," said Dr Das. Additionally, "this was advertised as a smoking study and not as a stop-smoking study."

Usual care consisted of NRT during hospitalization and brief quitting advice. The primary outcome measure for either treatment was verified 7-day "point prevalence abstinence" at 12 months.

Results showed a 22.1% total quit rate for the intervention group at the 12-month follow-up vs an 11% quit rate for the usual care group (odds ratio [OR], 2.30 with 95% confidence interval [CI] 1.08 - 4.90; P < .05; risk ratio (RR), 2.01 with 95% CI 1.05 - 3.83).

There were no significant between-group differences at this time point in drug and/or alcohol use.

However, secondary outcomes showed that the patients who quit smoking were significantly less likely to be drinking alcohol at 12 months (P = .002) or using cannabis (P = .03) than those who did not quit smoking. In fact, 22% of the patients who quit smoking were drinking, in comparison with 58% of the patients who continued to smoke; 18% of the patients who quit smoking were using cannabis, in comparison with 42% of those who continued smoking.

"Putting aside the intervention, we wanted to see if quitting smoking negatively affected these patients' substance abuse. And luckily, we didn't find that," said Dr Nas.

She added that "hospitalization is a great time to take advantage of treatment. This is a good place to get over their initial withdrawal, and there's more motivation to change with access to [NRT]."

The investigators note that the overall findings support integrating alcohol, tobacco, and drugs into one intervention.

"Combined treatment could lead to comprehensive care for a group at great risk of smoking-related morbidity and mortality," said Dr Nas, adding that Rx for Change is a free, online resource that provides tobacco treatment training for clinicians.

"Outstanding Evidence"

When asked during the Q&A session whether there were any increases in depression or other psychiatric symptoms after the patients quit smoking, Dr Nas said that initial findings are showing that at first, there was a slight increase in symptoms, which had leveled out at 12 months.

"This is outstanding evidence to talk with my patients about," session moderator Carla Marienfeld, MD, assistant professor of psychiatry at the Yale University School of Medicine, in New Haven, Connecticut, said to meeting delegates after the presentation.

Later, she told Medscape Medical News that it was a very promising study in a population that clinicians need to know more about.

"As presented, there's a lot of resistance in the psychiatric community to initiate smoking cessation because of the perception that you need to focus on other things first," said Dr Marienfeld, who was not involved with this research.

"We do our patients a disservice when we do that because there's evidence showing it's really not harmful to address that, and there are so many harms from smoking if we don't address it," she added.

The study authors have reported no relevant financial relationships.

American Academy of Addiction Psychiatry (AAAP) 25th Annual Meeting: Paper presentation 4, presented December 6, 2014.

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