why people with mental health conditions smoke so much and what to do about it john hughes...

Why People with Mental Health Conditions Smoke So Much and What To Do About It

John Hughes

University of Vermont, USA

john.hughes@uvm.edu

Disclosure

I have received grants, consulting fees or speaking fees from most of the priviate

companies, non-profits and governmental organizations prompting smoking

cessation devices, medication and services.

Nicotine, The “Renaissance”Drug

• Relieves anxiety and depression

• Relieves anger

• Improves concentration

• Decreases hunger

What Are the Problems Facing 16 yr Olds?

• Controlling mood

• Controlling anger

• Concentrating

• Controlling weight

• Occurs quickly after the behavior

• Frequent self-administration

• Effects occurs reliably

• No intoxication

• Requires few skills to obtain

Nicotine Via Cigarettes is the Perfect Reward

No disorder 43%

Major depression 38%

Anxiety disorders 33%

Alcohol/Drug 29%

Schizophrenia 27%

Bipolar 17%

Lifetime Smoking Cessation Rates by Psychiatric Disorder (Lasser 99)

Cause of Death in Recovering Alcoholics

Alcohol Tobacco Other0

20

40

60

80

100

120

Hurt et al, 1995

Att

rib

uta

ble

D

eath

s

Expenditures on Tobacco

• Smokers with schizophrenia spend 27% of income on tobacco

• Cf: In US, 20% spent on housing and 10% spent on food

Casual Flow of Depression and Smoking

(Breslau 1991)

• Depression predicts progress to daily smoking OR = 3.0

• Smoking predicts onset of depression OR = 1.9

Smokers with vs without Mental Health Conditions

• Fewer neversmokers (20% vs 55%)

• Fewer exsmokers (10% vs 25%)

• Fewer quit attempts (15% vs 45%)

• Less success when try to quit (10% vs 15%)

Ever Quit =

Success/Quit Attemptx

Number of Quit Attempts

The lower rate of lifetime cessation is as much due to

fewer quit attempts as to less success on a given attempt.

Examples of How Smoking Interacts with Dx and Tx of

Mental Health Disorders

Hints for Smoke-Free Facilities

• Explain rationale

– to decrease second hand smoke – to decrease initiation or relapse among never

or former smokers on ward– not to pressure you to quit

• Treat withdrawal with NRT

• Predicted disasters do not occur

Nicotine Withdrawal

• Anxiety• Restlessness• Irritability• Difficulty concentrating• Hunger/weight gain• Insomnia• Depressed mood• Decreased heart rate

Overlap in Nicotine Withdrawal and Mental Health

Diagnosis and Tx

Symptom Diagnosis

Irritability Drug withdrawalInsomnia Several disordersRestlessness AkathesiaWeight gain TCA side-effects

Smoking Abstinence Increases Drug Blood Levels

Fluphenazine Fluvoxamine Haloperidol Imipramine Oxazepam

CaffeineClomipramineClozarilClozapineDoxepin

0

20

40

60

80Blood Levels by Smoking Status

Smokers Nonsmokers Smokers Nonsmokers

Clozaril Fluvoxamine

Mental Health Disorder

General population

Pre-contemplation

43% 57%

Contemplation 38% 33%Preparation 19% 10%

Interest in Quitting Smoking

Interest in Quitting Smoking Among Those with Alcohol Problems

(Hall, 09)

• 44% - 80% want to quit in near future

• 25% want to stop concurrent with stopping alcohol

Ever Quit =

Number of Quit Attemptsx

Success/Quit Attempt

Lay Explanations of Behavior Change

• Cathartic event

• Sudden insight

• Large contingency

• Solid decision to change: “Just Do It”

Effect of Cumulative EventsScenario 1

Clinician Kids UncleAdvice Cough complain Embarrassed Dies

Precontemplation Contemplation Preparation

1 Year

Effect of Cumulative EventsScenario 2

Uncle Kids ClinicianDies Cough Complain Embarrassed Advice

Precontemplation Contemplation Preparation

1 Year

Effect of Not Presenting Cue

• When MDs do not mention smoking, smokers conclude – My use is not that problematic – The MD does not think I can change

Tips for Treating Smoking in Those with Mental Health Conditions

•Keep smoking cessation on problem list

•Motivate every few months using personal risks and discussing barriers

•Let patient decide timing

Prompting Quit Attempts

• Best done when less symptomatic • Set up as natural progression from conquering

one problem to taking on another one• Emphasize many quit without mental health

conditions

Addressing Smoking in People with Mental Health Conditions

• 90% of effort is prompting quit attempt

• 90% of time not be successful

• 90% of time will take several prompts

Relapse Curve in Self-Quitters

Proven Treatments • Behavioral Therapies

– Quitlines

– Groups

– Individual

• Medications

– Nicotine gum, inhaler, lozenge, patch, combinations

– Bupropion

– Varenicline

Behavioral Treatments

• Usually increase quitting by 1.5x

• Quitlines effective – but used by < 5%

• Group and individual effective but rarely available

• Internet and social media effective

• No recent progress in improving outcomes

• No reimbursement

• Few trained therapists

New Behavioral Treatments

• Mindfulness

• Acceptance Therapy

• Behavioral Activation Therapy

• Persistence Therapy

• Exposure Therapy

ORs for Effect of Proven Medications

Nicotine gum 1.7

Nicotine patch 1.7

Nicotine inhaler 2.1

Nicotine lozenge 2.1

Combined NRTs 2.4

OTC NRT 2.0

Bupropion 2.1

Varenicline 2.8

Better Use of Treatment

• Combined patch + ad lib NRT or Varenicline is

first line tx

• Pre-treatment

• Extended Treatment

•Continued use after a lapse

Other Medication Treatments Under Study

• Mouth spray• Faster oral NRT• Snus• True nicotine inhalers• Non-nicotine cigarettes• Cytisine • Sensory replacement• Vaccine

Varenicline and Psychological Adverse

Events

• Based on case reports

• Not found in meta-analysis of 39 trials

• Not found in five large real world data sets (total n > 55,000)

Types of Treatments Used

• No treatment 63%

• OTC Medications 25%

• Rx Medications 8%

• Talking tx 2%

• Internet 2%

Incidence of Treatment Use

• Smoking 25-35%

• Depression 25-50%

• Alcoholism 10-12%

Percent of Quit Attempts That are Unplanned

Larabie, 2005 52%

West, 2000 49%

Fergusen, 2009 40%

2/3rds of Rxs for varenicline are patient initiated

Non-Cessation Indications

• Reduction as preliminary to abstinence

• Reduction to reduce harm

• Withdrawal relief during temporary abstinence

Reduction in Unmotivated Smokers

No Tx Reduction Motivational

Quit Attempt 16% 43% 51%

6 Mo Quit 4% 18% 23%

Reduce-to-Quit

• Gradual cessation is common (35-60% of attempts)

• RTQ approved in many European countries and Canada

• Unlikely to be approved in US anytime soon

Tips for Treating Smoking in People with Mental Health

Conditions

•Tailored or more intensive treatment not essential

• Neither therapy nor meds are essential

•Monitor weekly to prevent remission of alcohol / drug problem

Tips for Treating Smoking in Those with Mental Health

Disorder

• Therapists already have many of the skills needed, only brief training needed for most clinicians

• Associate with nonsmoking friends

• Buddy systems with ex-smokers

Does Cessation Precipitate Psychiatric Relapse?

• 0-18% of smokers with past history of MDD relapse during abstinence

• The mental health of most smokers improves with abstinence

Long-term Effect of Smoking Cessation

Long-Term Effect of Cessation

Tips for Motivating Cessation in Patients with Mental Health

Conditions

• Combat prior messages that patient lacks ability to quit

•Consider small steps: e.g. reduction

• Reduction may not reduce health risks but does increase later quitting

Tips for Treating Smoking in People with Mental Health

Conditions• Recommend proven therapies

• Not necessary to use tailored or more intensive treatment

• Monitor closely to prevent remission of mental health condition

Summary

• Nicotine produces psychological benefits

• Smokers with mental disorders often die from smoking-related illnesses

• Those with mental disorders more likely to start and less likely to quit smoking

• Increasing quit attempts as important as, if not more important than, aiding quit attempts

Summary

• Social support, especially from peers, important

• May want to begin with reduction goal

• Mental health clinicians have many of the skills need to motivate and help smokers quit

• Acquiring expertise is easy

Summary

• May not need tailored or more intensive treatment

• Abstinence symptoms can mimic psychological symptoms

• Abstinence can change levels of psychiatric medications

• Abstinence may increase relapse of mental disorder in small minority

Association for the Treatment of Tobacco Use and Dependence

An organization of providers dedicated to the promotion of and increased access to evidence-based tobacco treatment for the

tobacco user.

www.attud.org