1. Smoking status should be evaluated and documented for every psychiatric patient and the degree of dependence should be documented (preferentially with the Fagerstrom Test for Nicotine Dependence, FTND)
2. As soon as the patient with any psychiatric disorder, excepting a substance-related disorder, is in a stable phase, i.e., with no recent or planned changes in medications and no urgent problems, consequences of tobacco dependence are to be explained and the patient should be actively motivated to quit smoking. Substance-dependent inpatients should be motivated as an integral part of their withdrawal treatment
3. A minimum amount of counseling on smoking cessation should be performed
4. Taking into account the possible side effects and contraindications in the therapeutic decision-making, suggestions to use nicotine replacement therapy, varenicline, or bupropion should be part of the interventions offered
5. In order to minimize relapse rates a contact within the first days after a quit day should be offered for motivational support and supervision of medical treatment
6. Follow-up visits should be arranged in order to increase long-term abstinence rates
20.9 Summary
A variety of psychiatric and neuropsychiatric disorders are associated with an increased smoking prevalence. The interaction between psychiatric disorders and smoking behavior remains complex and largely unknown. However, one of the key factors is the neurochemical properties of nicotine and in second order the many chemicals released during tobacco smoking. In addition to its highly addictive properties, nicotine can have protective effects in cases of neurological or psychiatric clinical pictures (neurodegenerative disorders), a quasi-therapeutic effect (schizophrenia and affective disorders), or a reinforcing function as desired by patients (other substance disorders). The underlying neurochemical bases of the desired and positive effects are the direct cholinergic or secondary dopaminergic, serotonergic, and noradrenergic effects of nicotine intake.
The causal coherences are of great interest for the understanding of the etiopathogenesis of neuropsychiatric clinical pictures. Also regarding possible therapeutic implications for neurodegenerative diseases and the development of new approaches in the treatment of addictions the research in this field is of major importance.
The presumed positive effects of nicotine are however largely overshadowed by the enormous negative impact of smoking (associated with the inhalation of more than 4,000 chemicals) on the health, morbidity, and mortality of patients with psychiatric disorders. These negative effects and the high prevalences of smoking should motivate the implementation of smoking cessation programs in every mental health care facility.
Finally it has to be taken into account that the obvious significance of the factor “smoking” for the mental state and the cognitive performance as well as the effect of medications has been underestimated in the past. Many investigations on psychiatric and neurological clinical pictures neglect the effects of smoking unreasonably and thus do not describe disorder-specific effects of certain psychotropic drugs but rather show pseudo-correlations caused by smoking or nicotine intake!
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