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27. Tobacco Use Disorder
Keywords
Tobacco use disorderNicotine dependenceSmoking statusMotivational interviewingPharmacotherapyNicotine replacement therapy (NRT)BupropionVareniclineEAGLES trialNicotine withdrawalTreatment cascadeChronic disease modelOpt-out careE-cigarettesEssential Concepts
The majority of patients with schizophrenia smoke cigarettes, around six to eight out of ten patients. Many smokers with schizophrenia are severely addicted to nicotine.
Psychiatrists are well qualified and positioned to take a leadership role in smoking cessation efforts for patients with serious mental illness.
All patients in your clinic need to have their smoking status assessed and documented. View it as a quality measure.
Assist smoking patients with schizophrenia with smoking cessation to reduce cardiovascular mortality and lung disease. Make smoking cessation an explicit treatment goal and offer help to all patients, regardless of motivation to quit.
Opt-out care and making treatment the default option may be necessary if we want to nudge more people toward smoking cessation. Waiting until patients opt in is not as effective as behavioral economics has clearly shown when it comes to nudging somebody toward a behavior.
Motivational interviewing is a useful technique to help those smokers who opt out of care to resolve ambivalence about making a change (from smoking to quitting), allowing them to decide for themselves that a change is not only possible but desirable.
Most patients with schizophrenia will need maximum treatment to successfully quit, including pharmacotherapy.
Varenicline is the most effective medication to initiate and sustain smoking cessation; it is well tolerated and does not cause more neuropsychiatric side effects than bupropion or nicotine replacement therapy. NRT alone may be mostly ineffective in long-term smokers with serious mental illness.
After a successful quit attempt, many patients with schizophrenia require long-term maintenance pharmacological treatment compared to more time-limited approaches for the general population.
Since the social environment has a large impact on smoking, assess who in the patient’s environment smokes.
Smoking reduces antipsychotic drug levels, particularly for olanzapine and clozapine, via induction of the 1A2 P450 enzyme.
The role and safety of e-cigarettes vis-à-vis established smoking cessation pharmacotherapy is unclear and requires further study. E-cigarettes may represent a harm reduction approach for patients seriously addicted to cigarettes. Patients who switch to e-cigarettes should switch over completely and not also smoke cigarettes.
“It’s easy to quit smoking. I have done it hundreds of times.”[1]
Usually attributed to Mark Twain, 1835–1919
The majority of patients with schizophrenia smoke cigarettes, often prior to onset of psychosis. Until the 1990s, in a typical community mental health center or inpatient setting, it was not unusual to have 80–90% of patients who smoke. While smoking rates may no longer be as dramatic, a recent survey found that 62% of schizophrenia patients were current smokers [2] although in some settings this rate may be as high as 80%. In our clozapine clinic, 40% are current smokers, 30% ex-smokers, and only 30% never smoked [3]. By means of comparison, the population rate of smoking in my home state of Massachusetts is now at a historic low of 14% (number for the year 2015) [4], very much in line with overall US numbers [5]. This difference in smoking between patients with schizophrenia and the general population represents a clear health disparity. Patients with schizophrenia are often heavy smokers (more than 20 cigarettes/day, including 2 or 3 packs/day), suggesting that many patients are severely addicted to nicotine.
Smoking is not only one of the Framingham risk factors for heart disease but also causes a host of smoking-related lung diseases that can lead to early death or reduced quality of life (lung cancer and chronic obstructive pulmonary disease) [6]. Smoking cessation greatly reduces the mortality risk for many of the smoking-related diseases: the average life expectancy of patients with schizophrenia would be transformed if they did not smoke. First-episode patients are at high-risk of becoming the next cohort of long-term smokers with schizophrenia, unless smoking cessation is pursued as aggressively as other treatment goals during a critical period for cardiovascular risk prevention [7].
Key Point
Smoking cessation is a core physician task, and psychiatrists in particular must be able to competently nudge patients toward a quit attempt (using motivational interviewing) and then help them quit and remain quit (using medications). Moreover, all members of the treatment team need to be on board with making smoking cessation a treatment priority in order to convey a coherent message to the patient [8].
Promoting smoking cessation represents a paradigm shift for psychiatry. Traditionally, smoking was seen to be part of the mental health culture; the smoke break continues to be part of some treatment settings to combat boredom. Mental health counselors who smoked themselves saw smoking with patients as an opportunity for engagement rather than as a problem. The tobacco industry played its own, nefarious role in slowing down the decline in smoking among psychiatric patients [9]. Today, some remain confused about the potential benefits of smoking in this population, such as calming patients or treating presumed nicotinic deficits. I have always been struck by the power of the self-medication hypothesis given the discrepancy between lack of convincing benefits of nicotine on cognition, for example [10] (if anything, smoking may impact cognition negatively), and obvious medical harm. As a result of powerful myths and ideas, however, nicotine use disorder has not been addressed as vigorously in this patient population as in the rest of society. These attitudes are changing, and most psychiatric treatment settings are today smoke-free, for example. Concerns about units becoming unmanageable due to violence once smoking bans went into effect turned out to be unfounded. If anything, the level of physical assaults has decreased, at least in units where bans were thoughtfully implemented with staff support and training [11]. It is encouraging that fewer younger patients with schizophrenia smoke compared to their older peers [2] which suggests a cohort effect. Only in the past several years, a not yet understood association between smoking and psychosis risk was noted in population-based samples that merits further study [12].
Key Point
See smoking as the threat it is for your patients, both in terms of health risk but also as a financial disaster when patients spend more than one third of their income on cigarettes. Psychiatrists, with their expertise in addictions and their frequent visits with patients, are ideally positioned to take the lead in smoking cessation. Moreover, our colleagues in medicine believe smoking cessation in “our patients” is our responsibility [13].
I cannot overemphasize the pernicious effects of low expectations. From social science research, we know that nothing is more effective in creating poor outcomes than having low expectations. I have been taught by many patients with schizophrenia that smoking cessation is possible, even in cases that seemed beyond hope. As Mark Twain recognized, sustained abstinence requires more than one attempt – on average, five attempts in ex-smokers from the general population. It is, however, incorrect to claim that severely addicted patients with schizophrenia do as well with smoking cessation as normal control-population cohorts. In some patients, harm reduction (smoking less) might be all that can be accomplished in a given quit attempt. Unfortunately, smoking less can lead to compensatory smoking with higher exposure to carbon monoxide (CO) and carcinogens. The literature is also pointing toward higher relapse rates in patients with schizophrenia once pharmacologic smoking cessation treatment is withdrawn, indicating that maintenance treatment might have to be provided for at least 1 year [14], perhaps even longer. For some patients, smoking remains a way of life, and they point to it as one of the few enjoyable activities they have left.
The next sections about assessment and treatment view smoking as a chronic relapsing substance use disorder caused by addiction to nicotine [15]. Viewed in this way, patients who smoke are successfully treated within the framework of chronic disease management (i.e., offered care that is continuous and coordinated on the professional side while also empowering patients to effectively manage their condition) [16]. At the systems level in your clinic, consider organizing your smoking cessation efforts around the treatment cascade framework (taken from HIV care): identify smoking status, link to smoking-specific care which may include you, treat with pharmacotherapy, and quit and remain quit as the main outcome [3]. The framework recognizes the need for population-based management (registry, identification of smokers, tracking of treatments and results) if we want to reduce smoking in serious mental illness. The desired outcome for all patients is to not smoke cigarettes, not even occasionally.
Assessment of Smoking Status
Obtain Smoking History
To help, you must first identify smokers. At the initial visit, obtain a good smoking history (age of first smoking, amount of current smoking, previous quit attempts, longest duration of previous abstinence, smoking-related health problems). For all practical purposes, regular smokers are addicted to nicotine and qualify for a diagnosis of nicotine use disorder. Get a good understanding of the patient’s life and who smokes in his environment. Smoking is a good example of the power of social networks: it is quite difficult to quit smoking if all your friends or household members smoke [17]. As part of every follow-up office visit, assess the patient’s amount of smoking and offer treatment. Although this might seem excessive, it is nevertheless useful for patients to know that you, as their psychiatrist, take smoking seriously and have smoking cessation as a treatment goal because you care for them. Do not forget that by now, many patients are aware of the downsides from smoking and want to quit, so the question of motivation may not be as critical or predictive of success as is often assumed. I admit that there is a small group of patients who get annoyed if you ask them about their smoking (the “anti-contemplation” group, as Dr. Ronald Diamond, a community psychiatrist from the University of Wisconsin referred to [personal communication]); I still do ask, with an apologetic smile.
Tip
You might want to consider smoking status as a “vital sign;” it is that important and a measure of the quality of care a patient receives. Add smoking status to a patient’s problem list. Is your patient a current, former, or never smoker? For current smokers, record the amount of smoking (e.g., one pack per day). Young patients who smoke occasionally may not consider themselves smokers, so ask broad-based: “Do you ever smoke cigarettes?” Don’t forget to inquire about other tobacco products and e-cigarettes.
“How soon after you wake up do you smoke your first cigarette?” (waiting 1 hour or more suggests low dependence)
“How many cigarettes to you smoke per day?” (Ten or less suggests low dependence).
The degree of biological dependence matters, as more severe addiction results in withdrawal and greater difficulties in quitting. Biological dependence is considered severe if more than 20 cigarettes are smoked and if smoking is one of the first things done after waking up (within 30 minutes). Note that this might not be valid if smoking is not ad lib (e.g., group home). The more severely addicted, the more intensive treatment may be necessary.
Motivate to Quit
Motivational interviewing is a helpful technique to help smokers resolve ambivalence they have about making a change (from smoking to not smoking). One important principle of motivational interviewing is that you never argue for change, but let the patient come to the conclusion that change is not only possible but desirable. For this to occur, the benefits of quitting must outweigh the benefits of continuing to smoke; have a patient list the positive things about smoking, not just the negative things, to clarify this for patients.
One concrete thing you can do is calculate a patient’s 10-year risk for a major cardiac event using Framingham risk scoring (see Additional Resources in Chap. 21 on how to do this). This might increase motivation to eliminate one major risk factor, smoking.
A note of caution: while we made some gains in treating tobacco dependence in patients with serious mental illness, prevalence of smoking remains high. Collectively, we may need to adopt an approach to tobacco that makes treatment the default option if we want to make further progress [19]. A default is the option that will occur if no action is taken. In this case, the default starts patients on treatment, unless a patient opts out (of the default). Opt-out care contrasts with our current approach of no treatment as the default where we wait until patients declare that they are ready for a quit attempt (i.e., until they opt in), at which point we offer treatment. You know from your own experience with behavioral economics that opt-out defaults are more powerful as no action is required [20] (e.g., if the opt-out default for your employer is to automatically put away some money for your retirement, you will end up with savings as you will simply go along with the default).
Key Point
Emphasizing motivation to quit as a precondition for treatment is a recipe for inaction. The default option should be that we offer treatment (opt-out care). Continue to engage those patients who opt out using motivational interviewing.
Help to Quit
Ask (about smoking) – “Do you smoke?” “Do you want to quit?”
Advise (against smoking and recommend quitting).
Assess (readiness to quit) – “Are you interested in quitting within the next month?” Note the Key Point on the previous page regarding the problem of the current opt-in approach. You may consider de-emphasizing motivation to quit and go straight to assist and not insist on making readiness to quit a precondition for treatment.
Assist (with smoking cessation) – Offer and start pharmacotherapy and refer to smoking cessation program.
Arrange (for follow-up) – See or call patient 1 week after quitting.
“Ask” corresponds to identifying your smokers in clinic (the vital sign sticker on the chart, paper, or electronic) and a quick check about their level of motivation to quit, as discussed above. “Advise and assess” are your core clinical responsibility in identified smokers, using motivational interviewing. At this stage, you might be more proactive and already offer treatment, particularly if you believe that our current opt-in approach to smoking cessation is limiting and motivation to quit overemphasized (see Key Point above about opt-out care) [19]. “Assist” requires you to be comfortable prescribing smoking cessation pharmacotherapy. Routine referrals to general smoking cessation programs can be difficult for patients with schizophrenia, so you might have to provide counseling yourself. (Although groups are probably more effective than 1:1 counseling.) For higher functioning patients who use the Internet, refer them to an internet website (see under Additional Resources below) or to 1-800-QUIT-NOW.
For long-term smokers, quitting can seem impossible, particularly if smoking is also a “habit” that fills loneliness and boredom. Intermediate, achievable goals, like temporary abstinence or a reduced number of cigarettes per day (or even simply delaying every cigarette by 20 minutes), not complete smoking cessation, are necessary and acceptable stepping-stones to eventual commitment to quitting for good.
Tip
Use motivational interviewing techniques to guide patients toward quitting if they opt out of treatment (e.g., have patients make a list of benefits from smoking, benefits from quitting, and barriers to quitting – feared weight gain could be a formidable obstacle). We used to assign patient to one of Prochaska and DiClemente’s five stages of change (i.e., pre-contemplation, contemplation, preparation, action, and maintenance/relapse); this may encourage inactivity on the part of the physician if somebody is labeled “pre-contemplation” [22]. You may want to drop this reference frame.
Pharmacotherapy for Smoking Cessation
Initiating Smoking Cessation Treatment
All patients who are attempting to quit should be offered drug therapy to eliminate nicotine withdrawal and block the reinforcing properties of nicotine. Three medications are FDA-approved for smoking cessation: nicotine replacement therapy (NRT), bupropion, and varenicline. In the general population, NRT and bupropion given alone roughly double quit rates compared to placebo [15]. Varenicline (a selective alpha-4 beta-2 nicotinic acetylcholine receptor partial agonist) is most effective, tripling your chances of quitting [23]. Tolerability of the available smoking cessation aids is generally good. The most frequent side effects are insomnia for bupropion (make sure to take second dose not at bedtime), abnormal dreams for the nicotine patch (make sure to take patch off before going to bed), and nausea for varenicline, in about 1/4 of patients (take with food and full glass of water). I would avoid bupropion in patients with an increased seizure risk [24, 25]. Combining varenicline with NRT represents an evidence-based approach that ought to be offered to those with severe addiction. In clinical trials, smoking cessation is usually accompanied by some form of counseling.
Offering smoking cessation pharmacotherapy may be essential, particularly in long-term smokers with schizophrenia [26]. It may even be necessary to use maximum pharmacological combination pharmacotherapy (bupropion or varenicline plus patch, which act synergistically plus high-dose nicotine replacement therapy (NRT; patch plus gum/inhaler/spray)) in order to be successful. On the other hand, combining varenicline with bupropion may not be an effective strategy [27].
The most effective agent, varenicline, had a somewhat difficult time as the FDA added a black box warning in 2009, warning about suicide which frightened many patients (contributing to 17,000 annual premature deaths that would have been avoided had varenicline prescriptions not dropped off as a result [28] – an example of the law of unintended consequences). This warning was removed in 2016 after a large (over 8000 subjects) clinical trial (known as the Evaluating Adverse Events in a Global Smoking Cessation Study or EAGLES trial) that evaluated the neuropsychiatric safety of varenicline and bupropion in comparison to nicotine and placebo showed increased rates of neuropsychiatric symptoms (aggression, depression, suicidal ideation, agitation) in all treatment groups, including the placebo group. While patients with psychiatric illnesses had more neuropsychiatric symptoms compared to their non-ill peers (the trial comprised about 50% of patients with a stable psychiatric diagnosis), there were no meaningful differences between the various treatments including placebo. The increased side effect rate during quit attempts is a marker of the difficult patient population, not an effect of the medications used to assist in quitting. The EAGLES results confirmed an earlier meta-analysis of bupropion for smoking cessation in schizophrenia that found no increase in positive symptoms [29]; this was a concern because of bupropion’s dopaminergic action. Given its superior efficacy and the severity of addiction in many patients with serious mental illness, varenicline should be a first-line choice unless there are specific concerns about its use. Close clinical monitoring during a quit attempt is important regardless of the medication used (i.e., regimen with or without varenicline) as some patients will experience neuropsychiatric side effects (around 10% in EAGLES across all treatments including placebo) that may require a change in the treatment plan.
- 1.
Set quit date, if possible.
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