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UNIVERSITY OF MIAMI AHEC - AREA HEALTH EDUCATION CENTER

L.J Ph: 305·689·5876 (1-877 -822-6669) Fax: 305·689·5897 UHealthSmokeFree.com

INFORMATION FOR MENTAL HEALTH PROVIDERS

1. Genetic Basis: smoking linked to depression, anxiety, and schizophrenia 2. Self-Medication : management of adverse side effects due to psychiatric meds 3. Psychological Factors: brief anxiety reduction , BUT linked to higher alcohol

dependence; studies show chronic nicotine use is 'anxiogenic' vs 'anxiolytic' 4. Trauma: link shown between smokers and early childhood trauma 5. Social Factors: low education/socio-economic status leads to higher smoking rates

Five Facts

1. Rates of smoking are 2-4 X higher in psychiatric and substance abuse disorders 2. Psychological problems decline significantly in smokers who stop for 6 months 3. Schizophrenics have almost 10 X higher risk of death from respiratory disease

than the general population 4. 44% cigarettes smoked in the U.S. are smoked by those with a psychiatric disorder 5. Quit rates are much lower for those with psychiatric disorders partly due to fact

that cost-effective cessation services are rarely offered

Five Myths

1. Allowing smoking is a 'harm reduction' approach----death toll from smoking FAR outweighs the 10% lifetime suicide risk in those with serious mental illness

2. Removing smoking privilege will lead to increased use of meds, restraints , or seclusion-----research shows the opposite to be true

3. Smoking ban is not realistic or practical with psychiatric patients----95% support total ban POST-implementation VS only 25% PRE-implementation

4. Removing smoking privilege will result in psychiatric decompensation---actually, highly nicotine dependent schizophrenics have WORSE outcomes

5. Admission rates will fall if facility smoke-free---- opposite more likely to be true

Five Benefits

1. Clean/health-promoting environment; non-smokers/X-smokers less likely to start 2. Eliminate "possession" disparity among patients 3. Improve safety by eliminating fire/burn hazard 4. Eliminate need to adjust/change psych med dosing based on smoking levels 5. Improve overall reputation of facility

FAQ's

1. Why should psychiatric units be "smoke-free"?

Answer: Smoking is the leading cause of preventable morbidity/mortality in U.S. which includes psychiatric patients!

2. What kind of support is recommended for inpatient psychiatric patients?

Answer: Combination of pharmacology, cognitive treatment, education, and support are recommended as nicotine dependence should be addressed in conjunction with the psychiatric illness.

PSYCHIATRIC DRUG INTERACTIONS IN SMOKERS:

1. Alprazolam (Xanax) Plasma concentrations decrease up to 50% among smokers.

2. Chlorpromazine (Thorazine) Smokers may experience less sedation and hypotension and require higher doses.

3. Clozapine (Clozaril)

4. Fluvoxamine (Luvox)

5. Haloperidol (Haldol)

6. Olanzapine (Zyprexa)

7. Tacrine (Cognex)

8. Tricyclic antidepressants

9. Benzodiazepines

10.0pioids

Increased metabolism via CYP1A2 induction resulting in 28% reduction in plasma concentration.

Increased metabolism via CYP1A2 induction resulting in 25% reduction in plasma concentration . Dosage changes not routinely recommended but smokers may require higher doses.

Clearance increased by 44% resulting in 70% decrease in serum concentration.

Increased metabolism via CYP1A2 induction resulting In 40-98% reduction in levels. Dosage changes not routinely recommended but smokers may require higher doses.

Increased metabolism via CYP1A2 induction, half-life decreased by 50% dropping serum levels 300%. Smokers may require higher doses.

Possible interaction with TCAs with decreased blood levels but clinical importance not established.

Decreased sedation and drowsiness which may be caused by CNS stimulation by nicotine.

Decreased analgesic effect; tobacco smoking may increase the metabolism of propoxyphene by 15-20% and pentazocine by 40% requiring higher dosage, mechanism unknown.

NICOTINE WITHDRAWAL SXS THAT OVERLAP WITH PSYCHIATRIC SXS:

Anxiety Restlessness Difficulty concentrating

Irritability Depressed Mood I ncreased Appetite

CONCURRENT SMOKING WITH NRT

F rustrationl Anger Insomnia

Evidence shows that concurrent use of NRT with smoking appears to be safe. Smokers are expert at titrating their dose of nicotine and will adjust their smoking behavior to get the plasma level they seek. If a patient wants to smoke while on the patch, this indicates they require combination therapy of patch plus intermittent NRT.

RESOURCES 1. "Smoking Cessation for Persons with Mental Iliness- A Toolkit for Mental

Health Providers", developed by the University of Colorado at Denver Department of Psychiatry

2. "Tobacco-Free Living in Psychiatric Settings- A Best-Practices Toolkit Promoting Wellness and Recovery", developed by the National Association of State Mental Health Program Directors