smoking cessation for persons with mental illness

Smoking Cessationfor Persons with Mental Illnesses

A Toolkit for Mental Health Providers

Table of ContentsOverview 1 AlarmingStatistics 12 AboutthisToolkit: 2 Whoisthistoolkitfor?HowdoIusethistoolkit?

Tobacco Use and Mental Illness1 SmokingandMentalIllness: 3 BiologicalPredispositions,PsychologicalConsiderations, SocialConsiderations,Stigma2 SpecificMentalDisorders: 4 Depression,Schizophrenia,OtherDisorders3 TobaccoIndustryTargeting 5

Assessment and Intervention Planning1 ReadinesstoQuitandStagesofChange: 7 StagesofChange,The5A’s(Flowchart,Actionsand Strategies),The5R’s(AddressingTobaccoCessationfor TobaccoUserUnwillingtoQuit)2 CulturalConsiderations: 13 RecommendationsforMentalHealthClinician,Resources

Smoking Cessation Treatment for Persons with Mental Illness1 KeyFindings 152 ComponentsofSuccessfulIntensiveInterventionPrograms 163 BehavioralInterventionsforSmokingCessation: 17 Overview,SANEprogram,MoreElementsof SuccessfulCounseling4 PrescribingCessationMedications: 19 Depression,Schizophrenia,BipolarDisorder

Relapse Prevention1 ComponentsofMinimalPracticeRelapsePrevention 232 ComponentsofPrescriptiveRelapsePrevention 23

Local and National Tobacco Cessation Resources 25

Toolkit References 27

Literature Review 33

Funding for this project was provided by:Tobacco Disparities Initiatives of the State Tobacco Education and Prevention Partnership (STEPP), Colorado Department of Public Health and the Environment

The Tobacco Cessation Toolkit for Mental Health Providers was developed by the University of Colorado at Denver and Health Sciences Center, Department of Psychiatry: Chad Morris, Ph.D.Jeanette Waxmonsky, Ph.D.Alexis Giese, M.D.Mandy Graves, MPHJennifer Turnbull

For further information about this toolkit, please contact:

Jeanette Waxmonsky, Ph.DUniversity of Colorado at Denver and Health Sciences Center4455 East 12th Avenue, A011-11Denver, Colorado 80220Phone: 303.315.9155Fax: 303.315.9343Email: [email protected].

Overview

1 AlarmingStatistics

2 AboutThisToolkit:

• Whoisthistoolkitfor?

• HowdoIusethistoolkit?

O V E R V I E W | 1

Why is a smoking cessation toolkit for persons with mental illnesses needed?

They need to quit.Consumersneedtobealiveto“recover”frommentalillnesses.Smokingcessationisakeycomponentofconsumer-driven,individualizedtreatmentplanning.

They want to quit.Peoplewithmentalillnesseswanttoquitsmokingandwantinformationaboutcessationservicesandresources.(Morrisetal,2006)

They can quit.Peoplewithmentalillnessescansuccessfullyquitusingtobacco.(Evinsetal.,2005;Georgeetal.,2002).Significantevidenceshowsthatsmokingcessationstrategieswork.

Note: Throughoutthistoolkittheterms“tobaccouse”and“smoking”areusedinterchangeably.Althoughwedonotspecificallyaddressspit-tobaccouse,thetoolkitisgenerallyapplicabletospit-tobaccousers.

“I’d love to quit – I just don’t know how.”– John, age 45

O V E R V I E W | 2

Alarming StatisticsApproximately 7.7 percent of Colorado’s adult population has a major mental illness.1

Forty-onepercentoftheseindividualsusetobacco.Theprevalenceofsmokingamongpeoplewithmentalillnessesisstartling.

By diagnosis:Majordepression 45-50percentBipolarmooddisorder 50-70percentSchizophrenia 70-90percent

Americanswithmentalillnessesrepresentanestimated44.3percentofthetobaccomarket.2

Americanswithmentalillnessesarenicotinedependentatratesthataretwotothreetimeshigherthanthegeneralpopulation.3

Becausepeoplewithmentalillnessesusetobaccoatgreaterrates,theysuffergreatersmoking-relatedmedicalillnessesandmortality.4

About this toolkitWho is this toolkit for?Thistoolkitwasdevelopedforabroadcontinuumofmentalhealthproviders.Materialsareintendedfordirectproviders,aswellasadministratorsandbehavioralhealthorganizations.

How do I use this toolkit?Thetoolkitcontainsavarietyofinformationandstep-by-stepinstructionabout:•Lowburdenmeansofassessingreadiness toquit•Possibletreatments•ReferraltoColoradocommunityresources

1] Morris et al., 20062] Grant et al., 2004, Lasser et al., 20003] Grant et al., 2004, Lasser et al., 20004] Grant et al., 2004

Quick FactsMental Illnesses and Tobacco Use

• 7.1%oftheU.S.populationhasapsychiatricillness;however,thispopulation consumesover34.2%ofallcigarettes.(Grantetal.,2004)

• IntheU.S.,personswithmentalillnessesrepresentanestimated44.3%ofthetobacco marketandarenicotinedependentatratesthatare2-3timeshigherthanthegeneral population.(Grantetal.,2004;Lasser,2000)

• InColorado,approximately7.7%oftheadultpopulationhasamajormentalillnessand 41%oftheseindividualsusetobacco.(Gieseetal.,2003)

• Smokingcessationisakeycomponentofconsumer-driven,individualizedtreatment planning.(Morrisetal.,2006)

• Personswithmentalillnesseswanttoquitsmokingandwantinformationoncessation servicesandresources.(Morrisetal.,2006)

• Personswithmentalillnessescansuccessfullyquitusingtobacco.(Evinsetal.,2005; Georgeetal.,2002)

• SmokingquitratesforindividualswithpsychiatricillnessareNOTsignificantlylower thanthegeneralpopulation.(el-Guebalyetal.,2002)

• Becausepersonswithmentalillnessesusetobaccoatgreaterrates,theysuffergreater smoking-relatedmedicalillnessesandmortality.(Grantetal.,2004)

References:

El-GuebalyN,CathcartJ,CurrieSetal(2002).Smokingcessationapproachesforpersonswithmentalillnessoraddictivedisorders.Psychiatric Services,53(9):1166-1170.

EvinsAE,MaysVk,RigottiNA,etal.(2001).Apilottrialofbupropionaddedtocognitivebehavioraltherapyforsmokingcessationinschizophrenia.Nicotine Tobacco Research,3(4):397-403.

GeorgeTP,VessicchioJC,TermineAetal.(2002b).Aplacebo-controlledstudyofbupropionforsmokingcessationinschizophrenia.Biological Psychiatry,52(1):53-61.

GieseA,MorrisC,OlincyA(2003).Needsassessmentofpersonswithmentalillnessesfortobaccoprevention,exposure,reduction,andcessation.ReportpreparedfortheStateTobaccoEducationandPreventionPartnership(STEPP),ColoradoDepartmentofPublicHealthandEnvironment.

GrantBF,HasinDS,ChouPS,StinsonFS,DawsonDA(2004).NicotinedependenceandpsychiatricdisordersintheUnitedStates:resultsfromthenationalepidemiologicsurveyonalcoholandrelatedconditions.Archives General Psychiatry,61(11):1107-1115.

LasserK,BoydW,WoolhandlerS,etal(2000).Smokingandmentalillness:apopulationbasedprevalencestudy.Journal of the American Medical Association,284:2606–2610.

MorrisCD,GieseJJ,DickinsonM,Johnson-NagelN.(2006).PredictorsofTobaccoUseAmongPersonsWithMentalIllnessesinaStatewidePopulation.Psychiatric Services,57:1035-1038.

TobaccoDisparitiesInitiativesoftheStateTobaccoEducationandPreventionPartnership(STEPP),ColoradoDepartmentofPublicHealthandEnvironmentwww.cdphe.state.co.us/pp/tobacco/tobaccohome.asp

TobaccoUseandMentalIllness

1 SmokingandMentalIllness:

• BiologicalPredispositions

• PsychologicalConsiderations

• SocialConsiderations

• Stigma

2 SpecificMentalDisorders:

• Depression

• Schizophrenia

• OtherDisorders

3 TobaccoIndustryTargeting

Smoking and mental illnesses: nicotine effects and other considerationsPeoplewithmentalillnesses:•usetobaccoathigherrates• arelesslikelytosucceedatcessationattempts•accessgeneralmedicalservicesandother communityresourcesrelativelyinfrequently• strugglewithstigmaonseverallevels•generallyexperienceagreaterburdenofmorbidity andmortalitythantheoverallpopulation.

Why do they smoke more?Researchersbelievethatacombinationofbiological,psychologicalandsocialfactorscontributetoincreasedtobaccouseamongpersonswithmentalillnesses.

Biological predispositionPersonswithmentalillnesseshaveuniqueneurobiologicalfeaturesthatmayincreasetheirtendencytousenicotine,makeitmoredifficulttoquitandcomplicatewithdrawalsymptoms.

Nicotineaffectstheactionsofneurotransmitters(e.g.dopamine).Forexample,peoplewithschizophreniawhousetobaccomayexperiencelessnegativesymptoms(lackofmotivation,driveandenergy).

Nicotineenhancesconcentration,informationprocessingandlearning.(Thisisespeciallyimportantforpersonswithpsychoticdisordersforwhomcognitivedysfunctionmaybeapartoftheirillnessorasideeffectofantipsychoticmedications).

Otherbiologicalfactorsincludenicotine’spositiveeffectsonmood,feelingsofpleasureandenjoyment.

Someevidencesuggeststhatsmokingisassociatedwithareducedriskofantipsychotic-inducedParkinsonism.

T O B A C C O U S E a n d M E N T A L I L L N E S S | 3

Tobacco use and mental illness


Psychological considerations•Tobaccousemaytemporarilyrelievefeelings oftensionandanxietyandisoftenusedtocope withstress.•Peopledevelopadailyroutineofsmoking.

Social considerations•Peoplemaysmoketofeel“partofagroup.”•Smokingisoftenassociatedwithsocialactivities.•Personswithmentalillnessesmaynothavealot ofactivitiestokeepthembusy.Whenthey’re bored,theymaysmokemore.•Thesiteofasocialactivitymaysupport tobaccouse.

Stigma•Providersoftenthinkthatpeoplewithmental illnessesareunabletoquitsmoking.•Symptommanagementoftentakesprecedence overpreventivehealthmeasures.

Specific mental disordersWhataresomeconsiderationsforsmokingcessationinregardtospecificmentaldisorders?

DepressionAmongpatientsseekingsmokingcessationtreatment,25-40percenthaveahistoryofmajordepressionandmanyhaveminordysthymicsymptoms.

Depressionhasbeenshowntopredictpoorersmokingcessationrates.Considerstartingorrestartingpsychotherapyorpharmacotherapyfordepressioninpatientswhostatethatdepressionintensifiedwithcessationorthatcessationcauseddepression.

Cognitivebehavioraltherapyfordepressionandantidepressantshasbeenfoundtoimprovesmokingcessationratesinthosewithahistoryofdepressionorsymptomsofdepression.

Forasmokerwithahistoryofdepressioncurrentlytakingantidepressantmedication,itisimportanttonotethatsomeantidepressantlevelswillincreasewithsmokingcessation.

Stress is a big trigger for me. I don’t know how to deal with stress.

– Cathi, age 32

What I did to keep from craving cigarettes for a while is just to keep busy, being with people, and talking and playing games and working and things like that. That’s what helped me.

– Robert, age 43

SchizophreniaPersonswithschizophreniawhosmokemaybelessinterestedintobaccocessation,makingstrategiestoenhancemotivationtoquitespeciallyimportant.

Whenmentalhealthconsumerswithschizophreniadotrytostop,manyareunsuccessful;thus,intensivetreatmentsareappropriateevenwithearlyattempts.

Thehighprevalenceofalcoholandillicitdrugabuseinconsumerswithschizophreniacaninterferewithsmokingcessation.

Thebloodlevelsofsomeantipsychoticscanincreasedramaticallywithcessation.Nicotinewithdrawalcanmimictheakathisia,depression,difficultyconcentratingandinsomniaseeninconsumerswithschizophrenia.

Other psychiatric disordersThereisinsufficientinformationtomakespecificrecommendationsabouttailoringtreatmentofsmokingcessationtotheneedsofsmokerswithotherpsychiatricdisorders.

Ingeneral,whenmentalhealthconsumersmakeanattemptatsmokingcessation,theyshouldbefollowedcloselytomonitorformoreseverenicotinewithdrawal,exacerbationoftheirpsychiatricdisorderandpossiblesideeffectsduetocessation-inducedincreasesinmedicationlevels.

Methylphenidate(Ritalin)andd-amphetamine(Dexedrine),stimulantscommonlyprescribedforbehavioralproblemsassociatedwithattentiondeficithyperactivitydisorder(ADHD)increaseratesofsmokingandthereinforcingeffectsofsmoking.Methylphenidateandd-amphetamineuseinearlylifeleadstoincreasedoddsofdailysmokinglaterinlife.

Tobacco industry targetingBy1977,smokerswerebecominga“downscalemarket.”RJReynoldsnotedthatlesseducated,lowerincome,minoritypopulationsweremoreimpressionable/susceptibletomarketingandadvertising.Tobaccocompaniesbegantargetingthesepopulations.Free cigarettes were distributed to homeless shelters, mental hospitals and homeless service organizations.Cigaretteswerepurchasedforthementallyillandhomelesssothatconsumerswouldsmoke“clean”cigarettes,notdirtycigarettesbutts.

Thetobaccoindustryhastargetedpsychiatrichospitalsforsalespromotionsandgiveaways.Theyhavemadefinancialcontributionstohomelessveteranorganizations,usingrelationshipstoadvancetheirpoliticalagenda.


I’ve been schizophrenic since I was 14. I was told more less when I went to the hospitals that cigarettes help control certain areas in my brain and the way we function out in society. I more or less became more of a smoker because I was told it would help me with my illness. I was taught more about it helping my illness than I was about cancer and stuff like that. – Marc, age 24


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AssessmentandInterventionPlanning

1 ReadinesstoQuitandStagesofChange:

• StagesofChange

• The5A’s(Flowchart,ActionsandStrategies)

• The5R’s(AddressingTobaccoCessationfor

TobaccoUsersUnwillingtoQuit)

2 CulturalConsiderations:

• RecommendationsforMentalHealthClinicians

• Resources

Readiness to quit and stages of changeTheStagesofChangeModel(alsoknownastheTranstheoreticalModel)illustratedbelowisusefulinrecognizingthatnicotinedependenceisachronic,relapsingdisorderwithmosttobaccousersinthegeneralpopulationrequiringfivetosevenattemptsbeforetheyfinallyquitforgood.Manypatientsdonotrealizethatitusuallytakesseveralattemptstostopusingtobaccoandwillneedmotivationtoattempttoquitiftheyhavebeenunsuccessfulinthepast.Itisusefultothinkoftobaccocessationasaprocessratherthananevent.

Onceapersonhasbeenidentifiedasatobaccouser,hisorherreadinesstoquitcanbedetermined.Thisisimportantbecausetobaccouserswhoarenotconsideringquittingappeartoneeddifferentinterventionsthanthosewhoareambivalentaboutquittingorthosepresentlyinterestedinquitting.TobaccousersinthePrecontemplationstage(notconsideringquitting)canbemovedtotheContemplationstagebyaskingconsumerstoconsiderthenegativeconsequencesoftobaccouseforthemandtheadvantagesoftobaccocessation(thisinformationhastobepersonalized).Itisworthwhiletoactivelyencouragequittingandoffersupportandtreatmentaswellasconveyingthemessagethatpersonswithmentalillnessescansuccessfullyquitusingtobacco.

Stages of change•Precontemplation:Nochangeisintendedinthe foreseeablefuture.Theindividualisnotconsidering quitting.•Contemplation:Theindividualisnotpreparedtoquitat present,butintendstodosointhenextsixmonths.•Preparation:Theindividualisactivelyconsidering quittingintheimmediatefutureorwithinthenext month.•Action:Theindividualismakingovertattemptstoquit. However,quittinghasnotbeenineffectforlongerthan sixmonths.•Maintenance:Theindividualhasquitforlongerthan sixmonths.

A S S E S S M E N T a n d I N T E R V E N T I O N P L A N N I N G | 7

Assessment and intervention planning


The 5 A’s: Ask, Advise, Assess, Assist and ArrangeTheU.S. Public Health Service Clinical Practice Guideline: Treating Tobacco Use and Dependenceprovideshealthcarecliniciansastrategyforsmokingcessationtreatmentthatisbuiltaroundthe“5A’s”(Ask,Advise,Assess,AssistandArrange).Knowingthatprovidershavemanycompetingdemands,the5A’swerecreatedtokeepstepssimple.

Onthefollowingpagesyouwillfindasummaryoftheseeasilyimplementedsteps.

TheGuidelinerecommendsthatallpeopleenteringahealthcaresettingshouldbeaskedabouttheirtobaccousestatusandthatthisstatusshouldbedocumented.Providersshouldadvisealltobaccouserstoquitandthenassesstheirwillingnesstomakeaquitattempt.Personswhoarereadytomakeaquitattemptshouldbeassistedintheeffort.Followupshouldthenbearrangedtodeterminethesuccessofquitattempts.

Thefull5A’smodelismostappropriateforagenciesandorganizationsthathavetobaccocessationmedicationsand/orbehavioralservicesavailableforconsumers.Foragenciesandorganizationsthatdonothavetobaccocessationservicesreadilyavailable,werecommendtheuseofthefirsttwoA’s(askandadvise)andthenrefertoavailablecommunityservices.Thefull5A’smodel,aswellastheabbreviatedask-advise-refermodelarepresentedintheflowchartandtablesatthebackofthisbook.

A S K

AD

VI S

E

AS

SESSASSIS

T

AR

RA

NG

E

Tobacco dependenceand use (current or former)

is a chronic relapsingcondition that requires

repeated interventions and a systematic approach.

If you have limited time:ASK ADVISE REFER

Strategies for Implementation

Clear:“Asyourclinician,Iwanttoprovideyouwithsomeeducationabouttobaccouseandencourageyoutoconsiderquittingtoday.”

Strong:“Asyourclinician,Ineedyoutoknowthatquittingsmokingisthemostimportantthingyoucandotoprotectyourhealthnowandinthefuture.TheclinicstaffandIwillhelpyou.”

Personalized:Tietobaccousetocurrenthealth/illness,itssocialandeconomiccosts,motivationlevel/readinesstoquit,and/ortheimpactoftobaccouseonchildrenandothersinthehousehold.

Seepatienteducationalbrochureatbackofthismanual.

Action

Inaclear, strong andpersonalizedmanner, adviseeverytobaccousertoquit.

Bemindfultoadviseinanon-judgmentalmanner.

Action

Forconsumersinterestedinquitting.


Provideinformationonlocalsmokingcessationresources.Youmayfindlocalresourcesathttp://www.co.quitnet.com/libraries/programs/.

Useproactivereferralifavailable:RequestwrittenconsumerpermissiontofaxtheircontactinformationtotheColoradoQuitLineorotherprogram.Informthepatientthecessationprogramstaffwillcontactthem.

Documentthereferral.

SeeColoradoQuitLinefaxreferralformatendofthissection.

Action

Askeveryconsumerateveryvisit,includinghospitaladmissions,iftheysmoke.


Withinyourpractice,systematicallyidentifyalltobaccousersateveryvisit.

Establishanofficesystemtoconsistentlyidentifytobaccousestatusateveryvisit.(Seeclinicexampleatendofthissection.)

Determinewhatformoftobaccoisused.

Determinefrequencyofuse.

Determinetobaccousestatus.

Makenoteofconsumersexposedtosecondhandsmoke.

Actions and Strategies for Mental Health Providers to Help Consumers Quit Smoking


ASK

REFER

ADVISE

Action

Assesswillingnesstomakeaquitattemptwithinthenext30days.

Determinewiththepatientthecostsandbenefitsofsmokingforhimorher.

Determinewherethepatientisintermsofthereadinesstochangemodel.

Assesspastquitattemptsandpast/currentpsychiatricsymptomsforconsumerswantingtoquit.


Assessreadinessforchange.Gotop.7tolearnhowtoassessreadinessforchange.

Iftheconsumerisreadytoquit,proceedtoAssist(below)and/orarrangeformoreintensiveservicestohelpwiththequittingprocess.

Iftheconsumerwillparticipateinanintensivetreatment,deliversuchatreatmentorrefertoanintensiveintervention(Arrange).

Iftheconsumerisn’treadytoquit,don’tgiveup.Providerscangiveeffectivemotivationalinterventionsthatkeepconsumersthinkingaboutquitting.Conductamotivationalinterventionthathelpsconsumersidentifyquittingaspersonallyrelevantandrepeatmotivationalinterventionsateveryvisit.

Foraddressingtobaccocessationwithtobaccousersunwillingtoquit,pleaseproceedtothe5R’sonpage12.

Fortheconsumerwhoiswillingtoquit:

Obtainasmokinghistoryandassessexperiencewithpreviousquitattempts:• Reasonsforquitting.• Anychangeinpsychiatricfunctioningwhenheorshetriedtostop?• Causeofrelapse(wasthisduetowithdrawalsymptomsorincreased psychiatricsymptoms?)• Howlongdidheorsheremainabstinent?• Priortreatmentintermsoftype,adequacy(dose,duration),complianceand consumer’sperceptionofeffectiveness.• Expectationsaboutfutureattemptsandtreatments.

Determinewhetherthereareanypsychiatricreasonsforconcernaboutwhetherthisisthebesttimeforcessation:• Istheconsumerabouttoundergoanewtherapy?• Istheconsumerpresentlyincrisis,oristhereaproblemthatissopressingthat timeisbetterspentonthisproblemthanoncessationatthisvisit?

• Whatisthelikelihoodthatcessationwouldworsenthenon-nicotinepsychiatric disorder?Andcanthatpossibilitybediminishedwithfrequentmonitoring,useof nicotinereplacementtherapyorothertherapies?

• Whatistheconsumer’sabilitytomobilizecopingskillstodealwithcessation? Ifthecopingskillsarelow,wouldtheconsumerbenefitfromindividualorgroup behaviortherapy?

• Istheconsumerhighlynicotinedependentordoestheconsumerhaveahistory ofrelapseduetowithdrawalsymptomsorincreasedpsychiatricsymptoms?Ifso, whichmedicationmightbeofhelp?

Increasingreadiness/motivation:Ifaconsumerwithpsychiatricillnessisnotreadytomakeaquitattempt,enhancemotivationanddealwithanticipatedbarrierstocessation.• Useproblemsolvingstrategies.• Increasemonitoringoftobaccouse.• Employbehavioraltherapyand/ornicotinereplacementtherapy.• Addressfearsofwithdrawalsymptomsorofworseningpsychiatricproblems.

A S S E S S M E N T a n d I N T E R V E N T I O N P L A N N I N G | 1 0

ASSESS

Action

Helptheconsumerwithaquitplan.

Recommenduseofapprovednicotinereplacementtherapy(NRT)and/orcounseling


Set a quit date,ideallywithintwoweeks.

Tellfamily,friendsandcoworkersaboutquittingandrequestunderstandingandsupport.

Anticipatetriggersorchallengestoplannedquitattempt,particularlyduringthecriticalfirstfewweeks.Theseincludenicotinewithdrawalsymptoms.Discusshowtheconsumerwillsuccessfullyovercomethesetriggersorchallenges.

Removetobaccoproductsfromtheenvironment.Priortoquitting,consumershouldavoidsmokinginplaceswheretheyspendalotoftime(e.g.work,home,car).

Forconsumerswithcognitivedifficulties(e.g.memoryorattentiondeficits)duetomentalillness,havethemwritedowntheirquitplan,sotheycanrefertoitlater.

RecommendtheuseofNRTmedicationstoincreasecessationsuccess.Discussoptionsforaddressingbehavioralchanges(e.g.cessationclasses,individualcounseling,telephonecoachingfromtheColoradoQuitLine)Encouragepatientswhoarereadytoquitthattheirdecisionisapositivestep.


ASSIST

Action

Schedulefollow-upcontact.


Timing.Followupcontactshouldoccursoonafterthequitdate,preferablywithinthefirstweek.Asecondfollow-upcontactisrecommendedwithinthefirstmonth.Schedulefurtherfollow-upcontactsasneeded.

Actionsduringfollow-upcontact:

Congratulate success!

Iftheconsumerhasrelapsed,reviewthecircumstancesandelicitrecommitmenttototalabstinence.• Remindpatientthatalapsecanbeusedasalearningexperience.• Identifyproblemsalreadyencounteredandanticipatechallengesinthe immediatefuture.• AssessNRTuseandproblems.• Consideruseorreferraltomoreintensivetreatment.• Give positive feedback about the patient’s attempts to quit. Individuals often cut down substantially on their tobacco use before quitting, and this harm reduction needs to be recognized and congratulated.

ARRANGE


The 5 R’s: Addressing Tobacco Cessation for the Tobacco User Unwilling to Quit(From Treating Tobacco Use and Dependence. Quick Reference Guide for Clinicians, October 2000. U.S. Public Health Service. www.surgeongeneral.gov/tobacco/tobaqrg.htm)

The“5R’s”Relevance,Risks,Rewards,RoadblocksandRepetition,aredesignedtomotivatesmokerswhoareunwillingtoquitatthistime.

Smokersmaybeunwillingtoquitduetomisinformation,concernabouttheeffectsofquittingordemoralizationbecauseofpreviousunsuccessfulquitattempts.Therefore,afteraskingabouttobaccouse,advisingthesmokertoquitandassessingthewillingnessofthesmokertoquit,itisimportanttoprovidethe“5R’s”motivationalintervention.

RelevanceEncouragetheconsumertoindicatewhyquittingispersonallyrelevant,asspecificallyaspossible.Motivationalinformationhasthegreatestimpactifitisrelevanttoaconsumer’smedicalstatusorrisk,familyorsocialsituation(e.g.,havingchildreninthehome),healthconcerns,age,genderandotherimportantpatientcharacteristics(e.g.,priorquittingexperience,personalbarrierstocessation).

RisksAsktheconsumertoidentifypotentialnegativeconsequencesoftobaccouse.Suggestandhighlightthosethatseemmostrelevanttothem.Emphasizethatsmokinglow-tar/low-nicotinecigarettesoruseofotherformsoftobacco(e.g.,smokelesstobacco,cigarsandpipes)willnoteliminatetheserisks.

Examplesofrisksare:

•Acuterisks:Shortnessofbreath,exacerbationof asthma,harmtopregnancy,impotence,infertility andincreasedserumcarbonmonoxide.

•Longtermrisks:Heartattacksandstrokes,lung andothercancers(larynx,oralcavity,pharynx, esophagus,pancreas,bladder,cervix),chronic obstructivepulmonarydiseases(chronicbronchitis andemphysema),longtermdisabilityandneed forextendedcare.

•Environmentalrisks:Increasedriskoflungcancer andheartdiseaseinspouses;higherratesof smokinginchildrenoftobaccousers;increased riskforlowbirthweight,SuddenInfantDeath Syndrome,asthma,middleeardiseaseand respiratoryinfectionsinchildrenofsmokers.

Every time I need a pack of cigarettes, that’s taking money out of my pocket. You can see everybody around here, people that aren’t smoking, look how much money they have. People that are smoking are pretty much broke. If I could quit smoking, I’d have more money to spend.

– James, age 37


RewardsAsktheconsumertoidentifypotentialbenefitsofstoppingtobaccouse.Suggestandhighlightthosethatseemmostrelevanttotheconsumer.

Examplesofrewardsfollow:• Improvedhealth•Foodtastesbetter• Improvedsenseofsmell•Moneysaved•Betterselfimage•Home,car,clothing,breathsmellbetter•Nomoreworryingaboutquitting•Setagoodexampleforchildren•Havehealthierbabiesandchildren•Nomoreworryingaboutexposingothers tosmoke•Feelbetterphysically•Performbetterinphysicalactivities•Reducewrinkling/agingofskin

RoadblocksAsktheconsumertoidentifyimpedimentstoquittingandnoteelementsoftreatment(problemsolving,medications)thatcouldaddressbarriers.

Typicalbarriersmightinclude:•Withdrawalsymptoms•Fearoffailure•Weightgain•Lackofsupport•Depression•Enjoymentoftobacco

RepetitionRepeatmotivationalinterventionseverytimeanunmotivatedconsumervisitstheclinicsetting.Tobaccouserswhohavefailedinpreviousquitattemptsshouldbetoldthatmostpeoplemakerepeatedquitattemptsbeforetheyaresuccessful.

Cultural ConsiderationsCulturalissuesshouldalsobeconsideredforthoseindividualsofdiverseracialandethnicbackgroundsastobaccocessationassessmentandservicesareoffered.

RecommendationsKeyfindingsfromtheSurgeonGeneral’sreport:(1998SurgeonGeneral’sReport,TobaccoUseAmongU.S.Racial/EthnicMinorityGroups)

Inthefourracial/ethnicgroupsstudied(AfricanAmerican,AmericanIndian/AlaskaNative,AsianAmerican/PacificIslanderandHispanic),AfricanAmericanmenbearoneofthegreatesthealthburdens,withdeathratesfromlungcancerthatare50percenthigherthanthoseofCaucasianmen.

Ratesoftobaccorelatedcancers(otherthanlungcancer)varywidelyamongmembersofracial/ethnicgroups.TheyareparticularlyhighamongAfricanAmericanmen.

Tobaccouseamongadolescentsfromracialandethnicminoritygroupshasbeguntoincreaserapidly,threateningtoreversetheprogressmadeagainstlungcanceramongadultsintheseminoritygroups.CigarettesmokingamongAfricanAmericanteenshasincreased80percentoverthelastsixyears–threetimesasfastasamongwhiteteens.

Thehighleveloftobaccoproductadvertisinginracial/ethnicpublicationsisproblematicbecausetheeditorsandpublishersofthesepublicationsmaylimittheleveloftobaccousepreventionandhealthpromotioninformationincludedintheirpublications.

Well, the first thing is you have to decide is that you’re really committed to doing it and then you try over and over and over until you finally get there, and eventually you get there. But it takes a lot of time and it’s not easy.

– Sandy, age 37


Recommendations for Mental Health CliniciansWhenworkingwithpersonswithmentalillnesseswhoarealsoofdiverseracial/ethnicbackgrounds,thementalhealthclinicianshould:

•Ask,Advise,Assistand/orReferallpatientswithregardtotobaccocessation.Thereisacriticalneedto delivereffectivetobaccodependenceeducationandinterventionstoethnicandracialminoritieswith mentalillnesses.

•Usecessationinterventionsthathavebeeneffectiveforpersonswithmentalillnesses(e.g.NRTorbuproprion incombinationwithindividualorgroupcounselingthatemploysmotivationalinterviewingorcognitive- behavioralstrategies).Avarietyofsmokingcessationinterventions(includingscreening,clinicianadvice, self-helpmaterialsandthenicotinepatch)havebeenproveneffectivefortobaccocessationinminority populations.

•Beculturallyappropriate,reflectingthetargetedracial/ethnicgroups’culturalvalues.Thismayincreasethe smoker’sacceptanceoftreatment.

•Conveycessationcounselingorself-helpmaterialsinalanguageunderstoodbythesmoker.

ResourcesFormoreinformationabouttobaccouseandinterventionforracial/ethnicpopulationsinColorado,pleaseseethefollowingonlineresources:

ColoradoTobaccoDisparitiesStrategicPlanningWorkingGroup:http://ctdsp.amc.org/

ColoradoStateStateTobaccoEducationandPrevention(STEPP):http://steppcolorado.com

ColoradoMinorityHealthForumforInformationonReducingHealthDisparitiesinColorado:http://www.coloradominorityhealthforum.org/

Example for Clinic Screening for Tobacco Use

From the U.S. Department of Health & Human Serviceshttp://www.surgeongeneral.gov/tobacco/tobaqrg.pdf

ACTION STRATEGIESforIMPLEMENTATION

Implementanoffice-widesystem Expandvitalsignstoincludetobacco thatensuresthat,foreverypatientat useoruseanalternativeuniversal everyclinicvisit,tobacco-usestatus identificationsystem. isqueriedanddocumented.

VITALSIGNS

BloodPressure:

Pulse: Weight:

Temperature: RespiratoryRate:

TobaccoUse(circleone):CurrentFormerNever

• Repeatedassessmentisnotnecessaryinthecaseoftheadultwhohasneverused tobaccoorhasnotusedtobaccoformanyyears,andforwhomthisinformationis clearlydocumentedinthemedicalrecord.

• Alternativestoexpandingthevitalsignsaretoplacetobacco-usestatusstickerson allpatientchartsortoindicatetobacco-usestatususingelectronicmedicalrecords orcomputerremindersystems.

ParticipantConsentforReleaseofInformationAuthorization to Release Information (reflects the requirements of 45 C.F.R. §164.508 August 14, 2002)

I,___________________________________,givepermissiontomyhealthcareprovidertoreleasemy

name,phonenumber,anddateofbirthtotheColoradoQuitLine(800-QUIT-NOW)quitsmoking/tobacco

programatNationalJewishMedicalandResearchCenter(contractorfortheColoradoQuitLinecallcenter),

1400JacksonStreet,Denver,Colorado,80206.

ThePURPOSEofthisreleaseistorequestthatNationalJewishMedicalandResearchCentermakean

initialphonecalltometodiscussparticipationintheColoradoQuitLineProgram.Iunderstandthe

informationtobereleased,thepurposeofthisrelease,andthattherearelawsprotectingconfidentialityof

information.Iunderstandthatoncereleased,myinformationmaybere-disclosed,andmaynolongerbe

protected.Iunderstandthatsigningthisformisnotaconditionofreceivingservices.

_________________________________________________________ Participant Signature Date

Thispatientmayusenicotinereplacementtherapy.

_________________________________________________________ Provider Signature Date

For more NRT program information please go to http://www.steppcolorado.com or call 1.800.QUIT.NOW.

PLEASEFAXORMAILTHISSIGNEDFORMTO:ColoradoQuitLineSpecialist Fax 1.800.261.6259 Mail ColoradoQuitLine NationalJewishMedicalandResearchCenter 1400JacksonSt.,M305 Denver,CO80206

(Participantname)

ReferringProvider(stamp/label/writein)

Name

Clinic/Facility

Address

City/State/Zip

Phone#

Fax#*

*REQUIREDTORECEIVECONFIRMATIONOFREFERRAL

PatientInformation

Name_______________________________________

Address_____________________________________

City/State/Zip_______________________________

Phone#______________________DOB__________

Besttimeanddaytocall_____________________

DoyouneedTTY? YesNo

Mayweleaveamessage? YesNo

Colorado QuitLine Referral Form

1.800.QUIT.NOW(1-800-784-8669)

FAX:800-261-6259

SignHere

SignHere

SmokingCessationTreatmentforPersonswithMentalIllnesses

1 KeyFindings

2 ComponentsofSuccessfulIntensive

InterventionPrograms

3 BehavioralInterventionsforSmokingCessation:

• Overview

• SANEProgram

• MoreElementsofSuccessfulCounseling

4 PrescribingCessationMedications:

• Depression

• Schizophrenia

• BipolarDisorder

Key findingsSmokingcessationmodelsforpersonswithmentalillnessesgenerallycombinenicotinereplacementtherapy(NRT)withCognitiveBehavioralTherapy(CBT),atypeofpsychotherapythatfocusesonchangingdysfunctionalthoughts,emotionsandbehavior.

CBTprogramsthatproducethemostsuccessfulquitratesforthementalhealthpopulationgenerallyhavegroupsofapproximately8-10individualsthatmeetonceaweekfor7-10weeks.

ConsumerswithschizophreniaseemtohavethehighestsuccesswhenCBTiscombinedwithNRTandstrategiestoenhancemotivation.ArandomizedcontrolstudybyBakeretal.(2006)foundthatatallfollow-upperiods,asignificantlyhigherproportionofsmokerswithapsychoticdisorderwhocompletedalltreatmentsessionswerecurrentlyabstinent,relativetoacomparisongroupofpersonsreceivingcareasusual,(pointprevalencerates:3months,30.0%vs.6.0%;6months,18.6%vs.4.0%;12months18.6%vs6.6%).Smokerswhocompletedalleighttreatmentsessionswerealsomorelikelytohaveachievedcontinuousabstinenceatthreemonths(21.4%vs.4.0%).

Thereisastrongdose-responserelationbetweenthesessionlengthofperson-to-personcontactandsuccessfultreatmentoutcomes.Intensiveinterventionsaremoreeffectivethanlessintensiveinterventionsandshouldbeusedwheneverpossible.

Haugetal.(2005)foundthatforpeoplewithdepression,smokingcessationwasbestpredictedbystageofchange,withthoseinpreparationenteringtreatmentmorequicklythancontemplatorsorprecontemplators.Thevariablesmostassociatedwithacceptingtreatmentwerenotseverityofsymptoms,butrathercurrentuseofpsychiatricmedicationsandperceivedabilitytosucceedinquitting.

S M O K I N G C E S S A T I O N T R E A T M E N T | 1 5

Smoking cessation treatment for persons with mental illnesses


Components of Successful Intensive Intervention Programs:Intensivecessationinterventionsshouldincludethefollowing(fromtheU.S.DepartmentofHealthandHumanServices,2000):

AssessmentAssessmentsshouldensurethattobaccousersarewillingtomakeaquitattemptusinganintensivetreatmentprogram.Otherassessmentscanprovideinformationusefulincounseling(e.g.stresslevel,presenceofpsychiatricsymptoms,stressors,othercomorbidity).Personswithmentalillnesseswhoareattemptingtoquitsmokingshouldbecarefullyassessedandmonitoredfordepressionandotherpsychiatricsymptomsateveryofficevisit.

Program clinicians Multipletypesofcliniciansareeffectiveandshouldbeused.Onecounselingstrategywouldbetohaveamedical/healthcarecliniciandelivermessagesabouthealthrisksandbenefitsanddeliverpharmacotherapy,andbehavioralhealthcliniciansdeliveradditionalpsychosocialorbehavioralinterventionslikecognitivebehavioraltherapy(CBT).

Program intensity Becauseofevidenceofastrongdose-responserelationship,theintensityoftheprogramshouldbe:•Sessionlength–longerthan10minutes.•Numberofsessions–4ormore.•Totalcontacttime–longerthan30minutes.

Program formatEitherindividualorgroupcounselingmaybeused.Proactivetelephonecounselingalsoiseffective.Useofadjuvantself-helpmaterialisoptional.Follow-upassessmentinterventionproceduresshouldbeused.

Type of counseling and behavioral therapies Counselingandbehavioraltherapiesshouldinvolvepracticalcounseling(problemsolving/skillstraining),aswellasintra-treatmentandextra-treatmentsocialsupport.

PharmacotherapyEverysmokershouldbeencouragedtousepharmacotherapies,exceptinthepresenceofspecialcircumstances.Specialconsiderationshouldbegivenbeforeusingpharmacotherapywithselectedpopulations(e.g.pregnancy,adolescents).Theclinicianshouldexplainhowthesemedicationsincreasesmokingcessationsuccessandreducewithdrawalsymptoms.Thefirst-linepharmacotherapyagentsinclude:bupropionSR,nicotinegum,nicotineinhaler,nicotinenasalsprayandthenicotinepatch.(SeePharmacotherapiesSectiononp.19andlaminatedsheetatbackofthismanual).


Behavioral Interventions for Smoking CessationUseofbriefpsychosocialinterventions,self-helpandsupportivetherapyhavebeenshowntobeeffectivewithgeneralmedicalpatientsbutmaynotbesufficientforconsumerswithpsychiatricproblems(APA,1996).Additionally,peoplewithmentalillnessesoftenhavefewersocialsupportsandcopingskills.Therefore,intensivebehavioraltherapyshouldbeconsideredforthesepeopleevenintheearlyquitattempts.Whenpossible,thementalhealthprovidershouldelicitconsumerpreferencesaboutgrouporindividualtherapy.Ifaconsumerhasaspecificissuethatmightunderminetobaccocessation(e.g.problemswithassertiveness),thementalhealthprovidermightworkonthisissueinindividualtherapywhiletheconsumeralsoattendsgrouptherapyfortobaccocessation.

Cessationprogramsforpeoplewithmentalillnessesincludeabout7-10sessions.Typically,thereis• anintroductiontotobaccohistoryandprevalence ofuse•educationaboutthepropertiesofnicotine,health effectsofnicotineandaddictivenatureofnicotine• areviewofthereasonswhypeoplesmoke•educationaboutwaysonecanquitsmoking,use ofmedicationanddevelopmentofaquitplan.

Asnotedabove,additionalsessionsareusefulforaddressingissuesthatarepertinenttopersonswithmentalillnesses(i.e.,developingcopingskillsforstressandanxiety).

TheSANEprograminAustralia(Strasser,2001)isoneeffectivegroupcounselingprogramforpersonswithschizophrenia.Itinvolvesteachingproblemsolvingskillsandcognitive-behavioraltechniquestoaidsmokingreductionandcessationmaintenance.Thegroupconsistsof10sessions,runbytwotrainedfacilitators.Thecontentconsistsofthefollowing:• IntroductiontotheProgram•ReasonstoQuit•BenefitsofQuitting•UnderstandingWhyWeSmokeandWays ofQuitting•WithdrawalSymptoms•SocialSupport•DealingwithStressandAnxiety•CopingwithDepression•AssertivenessTraining•AngerManagement•Smoke-FreeLifestyle•DealingwithHighRiskSituations

More Elements of Successful CounselingFurtherelementsofsuccessfulcounselingandsupportiveinterventionsareoutlinedinthefollowingtables(U.S.DepartmentofHealthandHumanServices,2000).

Practical counseling treatment component (problems solving/skills training

Recognizedangersituations:Identifyevents,stressors,internalstatesoractivitiesthatincreasetheriskofsmokingorrelapse.

Developcopingskills:Identifyandpracticecopingorproblemsolvingskills.

Providebasicinformationaboutsmokingandsuccessfulquitting.

Examples

NegativemoodPsychiatricsymptomsBeingaroundothersmokersDrinkingalcoholorusingdrugsExperiencingurgesBeingundertimepressure

Learningtoanticipateandavoidtemptation.Learningcognitivestrategiesthatwillreducenegativemoods.Accomplishinglifestylechangesthatreducestress,improvequalityoflifeorproducepleasure.Learningcognitiveandbehavioralactivitiestocopewithsmokingurges(e.g.distractingattention).

Anysmoking(evenasinglepuff)increasesthelikelihoodofafullrelapse.Withdrawaltypicallypeakswithin1-3weeksafterquitting.Withdrawalsymptomsincludenegativemood,urgestosmokeanddifficultyconcentrating.Informationontheaddictivenatureofsmoking.

Common elements of practical counseling


Additionally, staff and peer support are key factors in cessation counseling. Some common elements of each:

Supportive treatment component

Encouragethepatientinthequitattempt.

Communicatecaringandconcern.

Encouragetheconsumertotalkaboutthequittingprocess.

Examples

Sharethateffectivetobaccodependencetreatmentsarenowavailable.Notethatone-halfofallpeoplewhohaveeversmokedhavenowquit.Communicatebeliefintheconsumer’sabilitytoquit.

Askhowtheconsumerfeelsaboutquitting.Directlyexpressconcernandwillingnesstohelp.Beopentotheconsumer’sexpressionoffearsofquitting,difficultiesexperiencedandambivalentfeelings.

Askabout:Reasonstheconsumerwantstoquit.Concernsorworriesaboutquitting.Successtheconsumerhasachieved.Difficultiesencounteredwhilequitting.

Common elements of eliciting peer support and other resources


Supportive treatment component

Trainconsumersinsupportsolicitationskills.

Promptsupportseeking.

Arrangeoutsidesupport.

Examples

Showvideotapesthatmodelskills.Practicerequestingsocialsupportfromfamily,friendsandcoworkers.Aidconsumerinestablishingasmoke-freehome.

Helpconsumeridentifysupportiveothers.Calltheconsumertoremindhimorhertoseeksupport.Informconsumersofcommunityresourcessuchasquitlines.

Mailletterstosupportiveothers.Callsupportiveothers.Inviteotherstocessationsessions.Assignconsumerstobe“buddies”foroneanother.

Prescribing Cessation MedicationsUtilizethefrequencyofmentalhealthtreatmentvisitsasanopportunityformonitoringprogressinsmokingcessation.Additionally,smokingcessationstrategiesshouldbeintegratedandcoordinatedwithtreatmentsformentalillnesses.

Sincepeoplewithmentalillnessesappeartohavemorewithdrawalsymptomswhentheystopsmokingthanthegeneralpopulation,theuseofnicotinereplacementtherapy(NRT)eveninearlycessationattemptsisrecommended.

TheoptimaldurationofNRTisnotknown.Someindividualsappeartorequirelong-termuseofNRT(e.g.,≥6months),butalmostallindividualseventuallystopusingNRTandthedevelopmentofdependenceonNRTisrare.Thus,patientpreferenceshouldbethemajordeterminateforthedurationofNRT(American Psychiatric Association Practice Guidelines 2006: Treatment of Patients with Substance Use Disorders,2ndEdition,p54).

Cliniciansshouldcloselymonitoractionsorsideeffectsofpsychiatricmedicationsinsmokersmakingquitattempts.

DepressionConsiderbuproprionandnortriptylineforconsumerswithdiagnosesofdepression.Bupropion-SRhasbeendemonstratedtobethemosteffectiveindepressedpatients.Patientswhousebupropion-SRduringasmokingcessationprogramaremorelikelytobeabstinentatthequitdate.However,relapseishighfollowingthediscontinuationoftreatment(Evins,etal.,2005;George,etal.,2002).Additionally,bupropion-SRhashadadverseaffectsonpatientswithbipolardisorderand/orahistoryofeatingdisorders.Itshouldnotbeusedinthesepopulations(McNeill,2004).Additionalresearchonsmokerswithahistoryofdepressionsuggeststheusefulnessofthenicotinetransdermalpatch(Thorsteinssonetal.,2001)andnicotinegum(Kinnunenetal.,1996)forshort-termsmokingcessation.

StronglyconsiderbehavioraltherapiessuchasCognitiveBehavioralTherapy(CBT),assmokerswithdepressionarelikelytofailwithmoreminimalinterventions(Brownetal,2001).ImprovedcessationoutcomeswiththeadditionofCBThavebeenreportedfornortriptylineandnicotinegum(Halletal.,1998,1994).


SchizophreniaSmokingcessationprogramsthatusethenicotinetransdermalpatch(NTP)demonstratethehighestquitratesforpatientswithschizophrenia(Williams&Hughes,2003)asitaidsinwithdrawalsymptoms.WhentreatmentincludestheuseofNRTinpatientswithschizophrenia,Dalacketal.(1999)foundthatdyskinesiasdecreasedduringabstinenceintheplacebopatchcondition,butincreasedduringabstinenceintheactivepatchcondition.

NRTisassociatedwithsmokingcessationratesof27percentto42percentinsmokerswithschizophrenia(Addingtonetal.,1998;Chouetal.,2004;Georgeetal.,2000).Also,useofnicotinenasalspray,whichproducesthehigherplasmalevelsofnicotine,isassociatedwiththereductionofwithdrawalandcraving(Williamsetal.,2004).

Incontrolledtrials,pharmacologicaltreatmentwithsustained-release(SR)bupropionhasbeenefficaciousinpromotingabstinenceinpersonswithschizophrenia.Treatment-seekingsmokershaveshownsuccess(withshort-termabstinenceratesof11percentto50percent)withacombinationofbupropionSRandcognitive-behavioraltherapy(CBT)atboththe150mg/day(Evinsetal.,2001)andthe300mg/daydoses(Evinsetal.,2005;Gerogeetal.,2002).Bupropiontreatmentalsoseemstoreducethenegativesymptomsofschizophrenia(Weinberberetal.,2006).

Patientstreatedwithatypicalantipsychoticagents,suchasclozapine(Clozaril),smokeless(Georgeetal.,1995;McEvoyetal.,1999,1995)andhaveaneasiertimequitting(Georgeetal.,2002,2000)thanthosetreatedwithtypicalantipsychoticmedications.However,smokingcessationcancauseachangeinplasmaconcentrationsofpsychotropicagentsduetoadecreaseintheinductionofcytochromeP4501A2(Weinbergeretal.2006).Antipsychoticmedicationswhosemetabolismisaffectedbysmokinginclude:clozapine(Clozaril),fluphenazine

(Modecate),haloperidol(Haldol),andolanzapine(Zyprexa).Therefore,monitoringmedicationsideeffectsmaybeneededduringthefirstmonthafterquitting(Kalmanetal.,inpress;ZiedonisandGeorge,1997).Themetabolismofrisperidone(Risperdal)andquetiapine(Seroquel)doesnotappeartobeaffectedbysmoking(Strasser,2001).

Bipolar DisorderGlassmanetal.(1993)foundthatpersonswithbipolardisorder(BD)mayalsobeatriskforrecurrenceofdepressivesymptomsduringsmokingcessation.Interestingly,personswithBDshowageneticlinkagetothea7nAChRnicotinicreceptorlocusonchromosome15similartothatfoundforpersonswithschizophrenia(Leonardetal.,2001).Todate,therehavebeennoempiricallybasedtreatmentspublishedforsmokerswithBD(Weinberger,etal,2006).UseofNTPissuggestedforthispopulation.

Anxiety DisordersAlthoughpatientsreportthatsmokingreducesdepressionandanxiety,chronicnicotineuseinanimalstudiesispositivelycorrelatedwithincreasedanxiety(Irvineetal.2001).Itisuncleartowhatextentsmokersexperiencewithdrawalsymptomsandmisinterpretareductioninnicotinewithdrawalasanxietyrelief(ZiedonisandWilliams,2003).Cinciripiniandcolleagues(1995)foundthatsmokerswithhighlevelsoftraitanxietyreceivingbuspirone(BuSpar)versusplaceboweremorelikelytohaveremainedabstinentattheendofthetrialbutnotatfollow-up.AsnotedbyWeinbergeretal.,(2006),aplacebo-controlledstudybyHertzbergetal.(2001)ofbupropionSRforsmokerswithposttraumaticstressdisorder(PTSD)foundthatbupropionwaswelltoleratedandresultedinhigherratesofsmokingcessation(60percent)ascomparedtotheplacebo(20percent).


Also,inastudyofveteranswithpost-traumaticstressdisorderwhoweresmokersMcFallandcolleagues(2005)foundthatsmokerswhoreceivedtobaccotreatmentintegratedwiththeirpsychiatriccarewerefivetimesmorelikelythansmokerswhoreceivedseparatetreatmenttoreportabstinencefromsmokingninemonthsafterthestudy.ThesmokersreceivingtheintegratedtreatmentweremorelikelytouseNRTandtoreceivemoresmokingcessationsessions.Additionally,cognitivebehavioraltherapytechniquesthatincorporatecognitiverestructuringandexposuretherapytohelppersonslearntotolerateandbecomemorecomfortablewithphysicalsensationsmaybehelpfultopersonswithanxietydisorders(Morissetteetal.,2007).

Substance Use DisordersNotsurprisingly,concurrentuseofalcoholand/orotherdrugsisanegativepredictorofsmokingcessationoutcomesduringsmokingcessationtreatment(Hughes,1996).Long-termquitratesofsmokersinearlyrecoverfromsubstanceusedisorders(SUDs)arelow,atapproximately12percent(Kalman,1998;Sussman,2002).However,personswithapasthistoryofalcoholismdonodiffersignificantlyfromcontrolsubjectsintobaccotreatmentoutcomes(Hayfordetal.,1999).

Thecombinedeffectsofco-occurringsubstanceabuseandsmokingbehaviorsappeartosignificantlyinfluencethehighratesofsmokingcessationtreatmentfailure(Weinbergeretal.,2006).Therearefewstudiesofpharmacotherapeuticinterventionsforsmokinginsubstanceabusers,butsomeevidenceexistssuggestingthatnicotinereplacementandbehavioralapproachesareeffective(Burlingetal.,1996;Shoptawetal.,1996).Areviewoftobaccocessationstudiesbyel-Guebalyetal.(2002)foundthatquitratesrangedfromsevenpercentto60percentaftertreatmentandfrom13percentto27percentat12months.Todate,thereareno

publishedcontrolledstudiesusingbupropionSRinsmokerswithco-occurringSUDs,althoughthesestudiesareinprogress(Weinbergeretal.2006).

Thetimingofsmokingcessationtreatmentforsubstanceabusersremainscontroversial(Weinbergeretal,2006).Somestudiesfoundthatconcurrenttreatmentforsmokingandotherdrugsappearsnottobeassociatedwithincreaseduseofalcoholorotherdrugs(Burlingetal.,2001;Kalmanetal.,2004,2001).Josephetal.(2004)foundthatwhilepatientsinalcoholtreatmentareinterestedinsmokingcessation,participateintreatment,anddemonstratesuccess,theydidnotshowanybenefitfromconcurrenttobaccocessationtreatment.Infact,Josephetal.foundthatdrinkingoutcomeswereworsewithconcurrenttobaccotreatment,suggestingthattobaccocessationinterventionsshouldbeprovidedtopatientsafterintensivealcoholtreatmenthasbeencompleted.


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RelapsePrevention

1 ComponentsofMinimalPractice

RelapsePrevention

2 ComponentsofPrescriptive

RelapsePrevention

Most relapses occur soon after a person quits smoking, yet some people relapse months or even years after the quit date. Relapse prevention programs can take the form of either minimal (brief) or prescriptive (more intensive) programs.

Components of Minimal Practice Relapse PreventionTheseinterventionsshouldbepartofeveryencounterwithaconsumerwhohasquitrecently.Congratulateeveryex-tobaccouserundergoingrelapsepreventiononanysuccess.Stronglyencouragethemtoremainabstinent.Whenencounteringarecentquitter,useopen-endedquestionsdesignedtoinitiateconsumerproblemsolvingsuchas“Howhasstoppingtobaccousehelpedyou?”Encouragetheconsumer’sactivediscussionofthetopicsbelow:

•Thebenefits,includingpotentialhealthbenefitsthatthe consumermayderivefromcessation.•Anysuccesstheconsumerhashadinquitting(duration ofabstinence,reductioninwithdrawal,etc.).•Theproblemsencounteredorthreatsanticipatedto maintainingabstinence(e.g.,depression,weightgain, alcoholandothertobaccousersinthehousehold).

Components of Prescriptive Relapse PreventionDuringprescriptiverelapseprevention,aconsumermightidentifyaproblemthatthreatenshisorherabstinence.Specificproblemslikelytobereportedbyconsumersandpotentialresponsesfollow:

Lack of support for cessation•Schedulefollow-upvisitsortelephonecallswith theconsumer.•Helptheconsumeridentifysourcesofsupportwithin hisorherenvironment.•Refertheconsumertoanappropriateorganizationthat offerscessationcounselingorsupport.

R E L A P S E P R E V E N T I O N | 2 3

Relapse prevention

R E L A P S E P R E V E N T I O N | 2 4

Negative mood or depressionIfsignificant,providecounseling,prescribeappropriatemedications,orrefertheconsumertoaspecialist.

Strong or prolonged withdrawal symptomsIftheconsumerreportsprolongedcravingorotherwithdrawalsymptoms,considerextendingtheuseofanapprovedpharmacotherapyoradding/combiningmedicationstoreducestrongwithdrawalsymptoms.

Weight gain•Recommendstartingorincreasingphysical activity;discouragestrictdieting.•Reassuretheconsumerthatsomeweightgain afterquittingiscommonandappearstobe self-limiting.•Emphasizetheimportanceofahealthydiet.•Maintaintheconsumeronpharmacotherapy knowntodelayweightgain(e.g.,bupropionSR, nicotine-replacementpharmacotherapies, particularlynicotinegum).•Referconsumertoaspecialistorprogram.

Flagging motivation / feeling deprived•Reassureconsumerthatthesefeelings arecommon.•Recommendrewardingactivities.•Probetoensurethattheconsumerisnot engagedinperiodictobaccouse

Emphasize that beginning to smoke (even a puff) will increase urges and make quitting more difficult.

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LocalandNationalTobaccoCessationResources

STEPPHealthcareProviderWebSitehttp://www.cohealthproviders.com

STEPPhttp://www.steppcolorado.com

AmericanCancerSocietyhttp://www.cancer.org

AmericanHeartAssociationOfColoradohttp://www.americanheart.org

AmericanLungAssociationofColoradohttp://www.alacolo.org/

AmericanPublicHealthAssociationhttp://www.apha.org/

CentersforDiseaseControlandPreventionhttp://www.cdc.gov/tobacco

ColoradoClinicalGuidelinesCollaborativehttp://www.coloradoguidelines.org/

ColoradoTobaccoEducationandPreventionAlliancehttp://www.ctepa.org/

SocietyforResearchonNicotineandTobaccohttp://www.srnt.org

SurgeonGeneralhttp://www.surgeongeneral.gov/

L O C A L a n d N A T I O N A L T O B A C C O C E S S A T I O N R E S O U R C E S | 2 5

Local and national tobacco cessation resources

L O C A L a n d N A T I O N A L T O B A C C O C E S S A T I O N R E S O U R C E S | 2 6

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ToolkitReferences

Addington J, el-Guebaly N, Campbell W, et al (1998). Smoking cessation treatment for patients with schizophrenia. American Journal of Psychiatry, 155(7): 974–976.

Alsene, K. M., Mahler, S. V., & de Wit, H. (2005). Effects of d-amphetamine and smoking abstinence on cue-induced cigarette craving. Experimental and Clinical Psychopharmacology, 13, 209-218.

American Psychiatric Association (1996). Practice guidelines for the treatment of patients with nicotine dependence. American Journal of Psychiatry, October Supplement, 1-31.

American Psychiatric Association Practice Guidelines 2006: Treatment of Patients with Substance Use Disorders, 2nd Edition. Accessed online at: http://www.psych.org/psych_pract/treatg/pg/SUD2ePG_ 04-28-06.pdf

Baker, A, Richmond, R, Haile, M, et al. (2006). A randomized controlled trial of a smoking cessation intervention among people with a psychotic disorder. American Journal of Psychiatry, 163:1934-1942.

Brown RA, Kahler CW, Niaura R et al (2001). Cognitive-behavioral treatment for depression in smoking cessation. Journal of Consulting and Clinical Psychology, 69(3): 471- 480.

Burling TA, Burling AS, Latini D (2001). A controlled smoking cessation trial for substance-dependent inpatients. Journal of Consulting and Clinical Psychology, 69(2): 295- 304.

Burling TA, Salvio MA, Seidner AL, Ramsey TG (1996). Cigarette smoking in alcohol and cocaine abusers. Journal of Substance Abuse, 8(4): 445- 452.

T O O L K I T R E F E R E N C E S | 2 7

Toolkit references


ChouKR,ChenR,LeeJFetal(2004).Theeffectivenessofnicotine-patchtherapyforsmokingcessationinpatientswithschizophrenia. International Journal of Nursing Studies,41(3)321.

CinciripiniPM,LapitskyL,SeayS,etal(1995).Aplacebo-controlledevaluationoftheeffectsofbuspironeonsmokingcessation:differencesbetweenhigh-andlow-anxietysmokers.Journal of Clinical of Psychopharmocology,15(3):182-91.

DalackGW,Meador-WoodruffJH(1999).Acutefeasibilityandsafetyofasmokingreductionstrategyforsmokerswithschizophrenia.Nicotine and Tobacco Research,1(1):53-57.

DursunS,KutcherS(1999).Smoking,nicotine,andpsychiatricdisorders:evidencefortherapeuticrole,controversies,andimplicationsforfutureresearch.MedicalHypotheses,52:101–109.

El-GuebalyN,CathcartJ,CurrieSetal(2002).Smokingcessationapproachesforpersonswithmentalillnessoraddictivedisorders. Psychiatric Services,53(9):1166-1170.

El-GuebalyN,HodginsD(1992).Schizophreniaandsubstanceabuse:prevalenceissues.Canadian Journal Psychiatry,37:704–710.

EvinsAE,CatherC,DeckersbachTetal.(2005).Adouble-blindplacebo-controlledtrialofbupropionsustained-releaseforsmokingcessationinschizophrenia.Journal of Clinical Psychopharmacology,25(3):218-225.

EvinsAE,MaysVk,RigottiNA,etal.(2001).Apilottrialofbupropionaddedtocognitivebehavioraltherapyforsmokingcessationinschizophrenia.Nicotine and Tobacco Research,3(4):397-403.

FioreMC,BaileyWC,CohenSJ,etal.(2000).TreatingTobaccoUseandDependence.ClinicalPracticeGuideline.Rockville,MD:U.S.DepartmentofHealthandHumanServices.PublicHealthService.

GeorgeTP,SernyakMJ,ZiedonisDM,WoodsSW(1995).Effectsofclozapineonsmokinginchronicschizophrenicoutpatients.Journal of Clinical Psychiatry,56(8)344-346.

GeorgeTP,VessicchioJC,TermineAetal.(2002b).Aplacebo-controlledstudyofbupropionforsmokingcessationinschizophrenia.Biological Psychiatry,52(1):53-61.

GeorgeTP,ZiedonisDM,FeingoldAetal.(2000).Nicotinetransdermalpatchandatypicalantipsychoticmedicationsforsmokingcessationinschizophrenia.American Journal of Psychiatry,157(11):1835-1842.

GieseA,MorrisC,OlincyA(2000).Needsassessmentofpersonswithmentalillnessesfortobaccoprevention,exposure,reduction,andcessation.ReportpreparedfortheStateTobaccoEducationandPreventionPartnership(STEPP),ColoradoDepartmentofPublicHealthandEnvironment.

GlassmanAH,CoveyLS,DalackGWetal.(1993).Smokingcessation,clonidine,andvulnerabilitytonicotineamongdependentsmokers.Clinical Pharmacology & Therapeutics,54(6):670-679.

GrantBF,HasinDS,ChouPS,StinsonFS,DawsonDA(2004).NicotinedependenceandpsychiatricdisordersintheUnitedStates:resultsfromthenationalepidemiologicsurveyonalcoholandrelatedconditions.Archives of General Psychiatry,61(11):1107-1115.

HallSM,MunozRF,ReusVI(1994).Cognitive-behavioralinterventionincreasesabstinenceratesfordepressive-historysmokers.Journal of Consulting and Clinical Psychology,62(1):141-146.


HallSM,ReusVI,MunozRFetal(1998).Nortriptylineandcognitive-behavioraltherapyinthetreatmentofcigarettesmoking. Archives of General Psychiatry,55(8):683-690.

HaugNA,HallSM,ProchaskaJJ,etal(2005).Acceptanceofnicotinedependencetreatmentamongcurrentlydepressedsmokers.Nicotine & Tobacco Research,7(2):217-224.

HayfordKE,PattenCA,RummansTAetal(1999).Efficacyofbupropionforsmokingcessationinsmokerswithaformerhistoryofmajordepressionoralcoholism.British Journal of Psychiatry,174:173-178.

HertzbergMA,MooreSD,FeldmanME,BeckhamJC(2001).Apreliminarystudyofbupropionsustained-releaseforsmokingcessationinpatientswithchronicposttraumaticstressdisorder.Journal of Clinical Psychopharmacology,21(1):94-98.

HughesJR(1996).ThefutureofsmokingcessationtherapyintheUnitedStates.Addiction,91(12):1797-1802.

IrvineEE,BagnalastaM,MarconC,etal(2001)Nicotineself-administrationandwithdrawal:modulationofanxietyinthesocialinteractiontestinrats.Psychopharmacology,153:315-320.

JosephA,WillenbringM,NugentS,NelsonD(2004).Arandomizedtrialofconcurrentversusdelayedsmokinginterventionforpatientsinalcoholdependencetreatment.Journal of Studies on Alcohol,65(6):681-691.

KalmanD(1998).Smokingcessationtreatmentforsubstancemisusersinearlyrecovery:areviewoftheliteratureandrecommendationsforpractice.Substance Use & Misuse,33(10)2021-2047.

KalmanD,HayesK,ColbySM,etal(2001).Concurrentversusdelayedsmokingcessationtreatmentforpersonsinearlyalcoholrecovery.Apilotstudy.Journal of Substance Abuse Treatment,20(3):233-238.

KalmanD,LeeA,ChanE,etal(2004).Alcoholdependence,otherpsychiatricdisorders,andhealth-relatedqualityoflife:areplicationstudyinalargerandomsampleofenrolleesintheVeteransHealthAdministration.American Journal of Drug & Alcohol Abuse,30(2):473-487.

KalmanD,MorrisetteSB,GeorgeTP(2006).Co-morbidityofsmokingwithpsychiatricandsubstanceusedisorders.Psychiatric Times,15(1).Accessedonlineat:http://www.psychiatrictimes.com/showArticle.jhtml?articleId=177101047

KerM,LeischowS,MarkowitzI,etal(1996).Involuntarysmokingcessation:atreatmentoptioninchemicaldependencyprogramsforwomenandchildren.Journal of Psychoactive Drugs,28:47–60.

KinnunenT,DohertyK,MilitelloFS,GarveyAJ(1996).Depressionandsmokingcessation:characteristicsofdepressedsmokersandeffectsofnicotinereplacement.Journal of Consulting and Clinical Psychology,64(4):791-798.

Lambert,N.(2005).ThecontributionofchildhoodADHD,conductproblems,andstimulanttreatmenttoadolescentandadulttobaccoandpsychoactivesubstanceabuse.Ethical Human Psychology and Psychiatry,7,197-221.

LasserK,BoydW,WoolhandlerS,etal(2000).Smokingandmentalillness:apopulationbasedprevalencestudy.Journal of the American Medical Association(JAMA),284:2606–2610.

LeonardS,AdlerLE,BenhammouK,etal(2001)Smokingandmentalillness[Review].Pharmacology, Biochemistry, & Behavior,70:561-570.


LyonE(1999).Areviewoftheeffectsofnicotineonschizophreniaandantipsychoticmedications.Psychiatric Services,50:1346–1350.

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McEvoyJ,FreudenreichO,McGee,Metal(1995).Clozapinedecreasessmokinginpatientswithchronicschizophrenia.Biological Psychiatry,37(8):550-552.

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McNeill,A(2004).Smokingandpatientswithmentalhealthproblems.London,England:HealthDevelopmentAgency.

Morissette,SB,Tull,MT,Gulliver,SB,etal.(2007).Anxiety,AnxietyDisorder,TobaccoUse,andNicotine:ACriticalReviewofInterrelationships.Psychological Bulletin,133(2)245-272.

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LiteratureReview

L I T E R A T U R E R E V I E W | 3 3

Literature reviewIndividual Studies

Yr of Pub

2001

1998

2006

1996

2001

2000

Author

Acton,G.,Prochaska,J.,etal.

Addington,J.,el-Guebaly,N.,etal.

Baker,A.,Richmond,R.,Haile,M.,etal.

Borrelli,B.,Niaura,R.,etal.

Brown,R,,Kahler,C.,Niaura,R.,etal

Combs,D.&Advokat,C.

Article Name

Depressionandstagesofchangeforsmokinginpsychiatricoutpatients

Smokingcessationtreatmentforpatientswithschizophrenia

Arandomizedcontrolledtrialofasmokingcessationinterventionamongpeoplewithapsychoticdisorder

DevelopmentofMDDduringsmoking-cessationtreatment

Cognitive-behavioraltreatmentfordepressioninsmokingcessation

Antipsychoticmedicationandsmokingprevalenceinacutelyhospitalizedpatientswithchronicschizophrenia

Setting/ContactType

Outpatientpsychiatricresearchcenter;Survey

Outpatientpsychiatricresearchcenter;Facetoface

Outpatientmentalhealthclinicsorresearchcenter;Facetoface

Facetoface

Facetoface

Inpatient;Facetoface

Volume # /Issue #

AddictiveBehaviors,26(5)

AmericanJofPsychiatry,155(7)


JofClinicalPsychiatry,57(11)

JofConsulting&ClinicalPsych,69

SchizophreniaResearch,46(2-3)

Intervention

Correlationalstudy:205psychiatricoutpatientscompletedmeasuresofdepression(PRIME-MDandBDI-II)

50schizophrenicoutpatientsweredividedinto5groupswhometfor7weeklysmokingcessationprogramsessions

298regularsmokerswithapsychoticdisorderwererandomlyassignedtoatreatmentconditionconsistingof8individualonehoursessionsofmotivationalinterviewingandcognitivebehavioraltherapyorcontrol(treatmentasusual)

144non-depressedSstooktheBDIandtheHamiltonRatingScaleforDepression;txwasfluoxetine

Smokersw/MDDrandomizedtostandardCBTsmokingcessationtxorsmokingcessationtx+CBTtreatmentfordepression

Schizophrenicpatientswhosmokedandwereeitherreceivingatypicalantipsychotic(n=15),clozapine(n=6),oranotheratypicalantipsychotic(n=18)

Results

PatientswhohadneversmokedshowedlowerratesofMDDthanthosewhohadsmoked;patientsinearlystagesofchangedidnotshowmoreMDDordepressivesymptoms,butshowedmorenegativethoughtsaboutabstinence;suggestbuildingsmokingcessationinterventionsbasedonthetranstheoreticalmodelofchangeforusew/psychiatricpops.

42%ofpatientshadstoppedsmokingattheendofthegroupsessions,16%remainedabstinentat3mo,and12%at6mo.;nochangesineitherposornegsymptomsofschizophrenia.

Asignificantlyhigherproportionofsmokerswhocompletedalltreatmentsessionsstoppedsmokingateachofthefollow-uptimesthancontrols(pointprevalenceratesat3months:30%vs6%;6months:18.6%vs4%;12months18.6%vs4%).

5SsmetthresholdcriteriaforMDD.

SmokerwithrecurrentMDDandheavysmokerswhoreceivedCBT-Dweresignificantlymorelikelytobeabstinentthaninstandardtreatment.

Clozapinewasassociatedwithasignificantlylowerincidenceofsmokingthaneithertypicaldrugsorotheratypicalantipsychotics.


Yr of Pub

1990

2002

1999

2005

2004

Author

Covey,L,Glassman,A,etal.

Covey,L,Glassman,A,etal.

Dalack,G.,Becks,L.,etal.

Evins,A.,Cather,C.,etal.

Evins,A.,Rigotti,C.,etal.

Article Name

Depressionanddepressivesymptomsinsmokingcessation

Arandomizedtrialofsertralineasacessationaidforsmokerswithahistoryofmajordepression

Nicotinewithdrawlandpsychiatricsymptomsincigarettesmokerswithschizophrenia

Adouble-blindplacebo-controlledtrialofbupropionsustained-releaseforsmokingcessationinschizophrenia

Two-yearfollow-upofasmokingcessationtrialinpatientswithschizophrenia:Increasedratesofsmokingcessationandreduction

Setting/ContactType

Facetoface

Facetoface


Recruitedfromcommu-nitymentalhealthcenters;Facetoface

Facetoface

Intervention

Investigationintoresultsofabehaviorallyorientedsmokingcessationprogramshowedsmokersw/MDDhistoryhadlowersuccessrates

134smokerswithhistoryofMDDreceivedSertraline(n=68)ormatchingplacebo(n=66)1wkplacebowashout,9wkdouble-blind,placebo-controlledtreatmentphasefollowedbya9daytaperperiod,anda6mo.drugfreefollow-up;allreceivedintensiveindividualcessationcounselingduring9clinicvisits

19outpatientsw/schizophreniaorschizoaffectivedisorder;1dayofadlibitumsmokingfollowedby3daysofacutesmokingabstinencewhilewearing22mg/dayactiveorplacebotransdermalnicotinepatches,withareturnto3daysofsmokingbetweenpatchconditions

bupropion-SRvsplacebo;andCBT

2yrfollow-uptobupropiontxw/CBT

Results

Firstweek–frequencyandintensityofpsychologicalsymptoms,particularlydepressivemood,werehigheramongsmokerswithpastdepression;interventionsshouldattempttopreventdysphoricsymptomsduringacutewithdrawlperiodforMDDsmokers.

Sertralinetxproducedalowertotalwithdrawlsymptomscoreandlessirritability,anxiety,craving,andrestlessnessthanplacebo;howevernosignificantdifferencebetweenthegroups.

Dyskinesiaswerefoundtohavedecreasedduringabstinenceandplacebopatchtreatment,butincreasedduringabstinenceandtheactivepatchconditions.

Ssinbupropiongrpweremorelikelytobeabstinentfortheweekafterthequitdateandattheendoftheintervention;Ssinthebupropiongrphadahigherrateof4-wkcontinuousabstinence(wks8-12)andalongerdurationofabstinence;relapseishighfollowingthediscontinuation.

MoreSswereabstinentatfollowupthanwereabstinentattheendofthetrial;decreasedsmokingduringthetrialwaspredictiveoflatersmokingreduction.

Volume # /Issue #

ComprehensivePsychiatry,31(4)


Neuropsycho-pharmacology,21(2)

JofClinicalPsycho-pharmacology,25(3)

ClinicalPsychiatry,65(3)


Yr of Pub

1995

2002

2000

1997

1993

1991

2004

Author

George,T.,Sernyak,M.,etal.

George,T.,Vessicchio,J.,etal.

George,T.,Ziedonis,D.,etal.

Ginsburg,J.,Klesges,R.,etal.

Glassman,A.,Covey,L.,etal.

Greeman,M.&McClellan,T.

Haas,A.,Munoz,R.,etal.

Article Name

Effectsofclozapineonsmokinginchronicschizophrenicoutpatients

Aplacebocontrolledtrialofbupropionforsmokingcessationinschizophrenia

Nicotinetransdermalpatchandatypicalantipsychoticmedicationsforsmokingcessationinschizophrenia

Therelationshipbetweenahistoryofdepressionandadherencetoamulti-componentsmoking-cessationprogram

Smokingcessation,clonidine,andvulnerabilitytonicotineamongdependentsmokers

Negativeeffectsofasmoke-freeruleonaninpatientpsychiatryservice

Influencesofmood,depressionhistory,andtreatmentmodalityonoutcomesinsmokingcessation

Setting/ContactType

Facetoface

Facetoface

Facetoface

Facetoface

Facetoface

Inpatient;Facetoface

Facetoface

Intervention

29schizophrenicoutpatients;clozapinetxvsTYPneuroleptics

bupropion-SRvsplacebo

Ssw/schizoorschizoafftreatedw/NTP&w/eitherATYPorTYPantipsychotics;GToftheAmerLungAssnorGTforsmokersw/schizothatemphasizedmotivationenhancement,relapseprevention,socialskillstraining,andpsychoeducation

13wkCBG&randomassignmenttonicotinegum,appetitesuppressantgum,orplacebogum

Clonidine

SmokingbanoninpatientunitsataVeteransAffairsmedicalcenter

549Ss(28%w/historyofMDD);CBTvs.HE

Results

Therewasasigdecreaseinreporteddailyciguseafterclozapinetx.

Bupropion-SRincreasedsmokingabstinencerates;possymp–notaffected,negsympreduced;ATYPuseenhancesmokingcessationresponsestoBUP.

EffectsofNTParemodestinschizophrenicpatients;nodifferenceinGTprograms;ATYPmaybesuperiortoTYPincombinationw/NTPforsmokingcessationinschizophrenicpatients.

GroupCBTisaneffectivesmoking-cessationprogramforwomenwithahistoryofdepressionwhoarenotcurrentlydepressed.

MDDpredicttxfailure;anincreasedriskforpsychiatriccomplicationsaftersmokingcessationwasapparentamongsmokerwithMDD,particularlybipolar.

20-25%ofpatientswhosmokedhaddifficultyadjustingtotherule,andsomepatientsexperiencedmajordisruptionintheirtx.

MDD-RSshadhigherratesofabstinenceinCBTcomparedw/HE,evenwhenthecontributionofmoodandtheinteractionbetweenmoodandanMDDxtxvariablewereincludedinthemodel.

Volume # /Issue #

JofClinicalPsychiatry,56(8)

BiologicalPsychiatry,52(1)



ClinicalPharmacology&Therapeutics,54(6)

Hospital&Community,42(4)

JConsultClinPsychol,72(4)


Yr of Pub

1994

1998

1996

2005

Author

Hall,S.M.,Reus,V.I.,MunozR.F.,etal



Haug,N.A,Hall,S.M.Prochaska,J.J.etal.

Article Name

Cognitive-behavioralinterventionincreasesabstinenceratesfordepressive-historysmokers

NortriptylineandCBTinthetreatmentofcigarettesmoking

Moodmanagementandnicotineguminsmokingtreatment:Atherapeuticcontactandplacebo-controlledstudy

Acceptanceofnicotinedependencetreatmentamongcurrentlydepressedsmokers

Setting/ContactType

Facetoface

Facetoface

Facetoface

Outpatientpsychiatricresearchcenter;Self-reportandstructuredinterviewmeasures

Intervention

149smokers(31%hadahistoryofMDD);allreceived2mg/dayofnicotinegum;MMprovidedin10groupsessionsover8wks;standardtxprovidedin5gpsessionsover8wks

HxofMDDvs.NohxofMDDrandomizedtoNortriptylinevs.placeboandCBTvs.control

Moodmanagement(MM)vs.contact-equivalenthealtheducation(HE);and2mgto0mgofnicotinegumforsmokersw/historyofMDD

Thisstudyreportsonbaselinecharacteristicsassociatedwithacceptanceandrefusalofavailablesmokingtreatmentamongcurrentlydepressedsmokersinapsychiatricoutpatientclinic.Thesample(N=5154)was68%femaleand72%White,withameanageof41.4yearsandaveragesmokingrateof17cigarettes/day.Allparticipantswereassignedtoarepeatedcontactexperimentalcondition;receivedastage-basedexpertsystemprogramtofacilitatetreatmentacceptance;andwerethenofferedsmokingtreatment,consistingofbehavioralcounseling,nicotinepatch,andbupropion

Results

Ssw/MDDweremorelikelytobeabstinentwhentreatedw/MM,andlessangeratbaselinewaspredictiveofabstinence.

Nortriptyline-higherabstinenceratesthanplacebo,independentofdepressionhx.CBT-Moreeffectivefor+hxMDD.Smokerswithhxofdepressionareaidedbymoreintensivepsychosocialtreatments.

MMandHEproducedsimilarabstinencerates:2mggumwasnomoreeffectivethanplacebo;MDDpatientshadagreaterincreaseinmooddisturbanceafterthequitattempt;MDDpatientsmaybebesttreatedbyinterventionsprovidingadditionalsupportandcontact,independentoftheraputiccontact.

Thenumberofdaystotreatmentacceptancewassignificantlypredictedbystageofchange,withthoseinpreparationenteringtreatmentmorequicklythancontemplatorsorprecontemplators.Inalogisticregression,thevariablesmoststronglyassociatedwithacceptingtreatmentwerecurrentuseofpsychiatricmedicationandperceivedsuccessforquitting.Severityofdepressivesymptoms,durationofdepressionhistory,andhistoryofrecurrentdepressionwerenotrelatedtotreatmentacceptance.Findingshaveimplicationsforthepsychiatricassessmentandtreatmentofsmokersinclinicalsettings.Psychiatricmedicationmayplayasignificantroleinsmokingcessationtreatmentacceptancebycurrentlydepressedsmokers.

Volume # /Issue #

JConsultClinPsychol,62(1)

ArchivesGenPsych,55

JofConsulting&ClinicalPsych,64(5)

Nicotine&TobaccoResearch,7(2),(April2005)217–224


Yr of Pub

1999

2000

2000

1997

2002

1998

Author

Hayford,K.,Patten,C.,etal.

Keuthen,N.,Niaura,R.,etal.

Lucksted,A.,Dixon,L.,etal.

Martin,J.E.,Calfas,K.J.,PattenCA,etal.

Niaura,R.,Spring,B.,Borelli,B.,etal.

Patten,C.A.,Martin,J.E.,Meyers,M.G.,etal.

Article Name

Efficacyofbupropionforsmokingcessationinsmokerswithaformerhistoryofmajordepressionoralcoholism

Comorbidity,smokingbehaviorandtreatmentoutcome

Afocusgrouppilotstudyoftobaccosmokingamongpsychosocialrehabilitationclients

Prospectiveevaluationofthreesmokinginterventionsin205recoveringalcoholics:One-yearresultsofProjectSCRAP-Tobacco

Multicentertrialoffluoxetineasanadjuncttobehavioralsmokingcessationtreatment

Effectivenessofcognitive-behavioraltherapyforsmokerswithhistoriesofalcoholdependenceanddepression

Setting/ContactType

Facetoface

Facetoface

Facetoface

Facetoface

Facetoface

Facetoface

Intervention

615smokersreceivedplaceboorbupropion-SRat100,150,or300mg/dayfor6wksaftertargetquitdate

120smokers;10wksmokingcessationtrialw/fluoxetine&behavioraltx;62.3%ofSswerediagnosedwithalifetimemood,anxietyorSUD

5focusgroups(6-10Sseach)40clientsinpsychosocialrehabilitationprograms.Discussedprosandconsofsmokingandnotsmoking.

Randomized:standardtreatment(ALAquitprogram+nicoticeanonymousmeetings)(ST),behavioralcounseling+exercise(BEX),orbehavioralcounselingplusnicotinegum(BNIC)

Randomizedto3doseconditions:10weeksofplacebo,30mg,or60mgfluoxetineplus9weeksCBT

Randomized:behavioralcounseling(BC)orBC+CBT

Results

Doseresponseeffectoftxforsmokingcessationwasfound.

Lifetimecomorbiditywasrelatedtohighersmokingratesandnicotinedependence,depressedmoodandgreaterselfreportofanxietyandstress.BaselinescoresontheBDIwererelatedtotxoutcomeforSsw/opositivehistoryofanypsychiatricdisorder,withlowerBDIscoresmorefreqinthosewhowereabstinent.

Resultsindicatethatissuesandneedsthatarespecifictosmokerswhousementalhealthservicesmustbeaddressedinthedevelopmentofsmokingpreventionandcessationinterventionsinpsychosocialrehabilitationandothermentalhealthprograms.

BEX=significantlyhigherquitratesatpost-treatment,notat6or12months.

Analysesassumingmissingdata=smokingobservednotreatmentdifferenceinoutcomes.Pattern-mixtureanalysisthatestimatestreatmenteffectsinthepresenceofmissingdata=enhancedquitratesassociatedwithboththe60-mgand30-mgdoses.

SignificantlymoresmokersinCBTquitatpost-treatmentand12monthfollowup.

Volume # /Issue #

BritishJofPsychiatry,174

Psychotherapy&Psycho-somatics,69(5)

PsychiatricServices,51(12)



JofStudiesonAlcohol,50(3)


Yr of Pub

2000

1997

2006

2001

1997

Author

Patten,C.A.,Martin,J.E.,Calfas,K.J.,etal.

Rabois,D.,Haaga,D.

Thorndike,F.P.,Friedman-Wheeler,D.G.,Haaga,D.A.

Weiner,E.,Ball,M.P.,Summerfelt,A.,etal

Ziedonis,D.M.,George,T.P.

Article Name

Briefreporteffectofthreesmokingcessationtreatmentsonnicotinewithdrawalin141abstinentalcoholicsmokers

Cognitivecoping,historyofdepression,andcigarettesmoking

Effectofcognitivebehaviortherapyonsmokers’compensatorycopingskills

Effectsofsustained-releasebupropionandsupportivegrouptherapyoncigaretteconsumptioninpatientswithschizophrenia

Schizophreniaandnicotineuse:Reportofapilotsmokingcessationprogramandreviewofneurobiologicalandclinicalissues

Setting/ContactType

Facetoface

Interview

Facetoface


Facetoface

Intervention

Randomizedto12weekprogramofStandardTreatment,behavioralcounselingplusexercise,orbehavioralcounselingplusnicotinegum

TestedpremisethatformerlydepressedsmokersarelackingincognitivecopingskillstaughtinCBT.4groups(depressed/not,smoker/not)completedWORtotestcognitivecoping

RandomizedtoCBTorcomparisonconditionofeducationandscheduledsmokingreduction.(uniquetoCBTconditionwascognitiverestructuringformoodmanagement)

9sessionsofweeklygrouptherapyinconjuctionwithopenlabelbupropiontreatment(150mg/twiceaday)for14weeks

24schizophrenicpatients:Nicotinereplacement,motivationalenhancementtherapy,andrelapsepreventionbehavioraltherapy

Results

Nosignificanteffectoftreatmentonpercentagereductioninsmokingrate.All3groupsshowedsimilaroverallreductionsinsmokingrate.

HxofdepressionassociatedwithsignficantlymorenegativeresponsesonWOR.“Thisstudysuggeststhatpeoplewithahistoryofdepressiontendtolacksuchskillsandmightthereforeespeciallybenefitfromincorporationofcognitivebehaviortherapyprinciplesinsmoking-cessationprograms.”

CBTgroupdidNOTshowmoreimprovementincompensatorycopingskills(measuredbyWaysofResponding).AnonsignificanttrendfavoringCBTwasfoundinpost-treatmentabstinence.

Noneofthesubjectsquitsmoking.However,measuredchangeinexpiredbreathcarbonmonoxidelevelsindicatedreductioninsmoking.

50%completedtheprogram,40%decreaseduseby50%,and13%remainedabstinentfor6months.

Volume # /Issue #

AddictiveBehaviors25(2)


AddictBehav,Jan18

AmJofPsychiatry,158

SchizophreniaBulletin,23(2)


Review Articles

Yr of Pub

1992

1998

1999

2002

1995

2003

1993

2001

1998

Author

Dalack,G.W.&Glassman,A.H.

Dalack,G.W.,Healy,D.J.,etal.

Dursun,S.M.&Kutcher,S.

el-Guebaly,N.&Cathcart,J.

Hughes,J.R.&Frances,R.J.

Martinez-Raga,J.&Keaney,F.

Resnick,M.P.

Ziedonis,D.,Krejci,J.,etal.

Ziedonis,D.M.,Wyatt,S.A.,etal.

Article Name

Aclinicalapproachtohelppsychiatricpatientswithsmokingcessation

Nicotinedependenceinschizophrenia:Clinicalphenomenaandlaboratoryfindings

Smoking,nicotineandpsychiatricdisorders:evidencefortherapeuticrole,controversiesandimplicationsforfutureresearch

Smokingcessationapproachesforpersonswithmentalillnessoraddictivedisorders

Howtohelppsychiatricpatientsstopsmoking

TreatmentofnicotinedependencewithbupropionSR:Reviewofitsefficacy,safetyandpharacologicalprofile

Treatingnicotineaddictioninpatientswithpsychiatricco-morbidity

Integratedtreatmentofalcohol,tobacco,andotherdrugaddictions

Currentissuesinnicotinedependenceandtreatment

Volume # /Issue #

PsychiatricQuarterly,63(1)


MedicalHypotheses,52(2)

PsychiatricServices,53(9)

Psychiatric`Services,46(5)

AddictBiol,8(1)

Nicotineaddition:Principlesandmanagement,pp.327o-336(eds:Orleans,C.T.&Slade,J.D.)

Integratedtreatmentofpsychiatricdisorders(ed:Kay,J.)Reviewofpsychiatry,20(2)

Newtreatmentsforchemicaladdictions(eds:McCance-Katz,E.F.&Kosten,T.R.)Reviewofpsychiatryseries.

Conclusions/Discussion

Adiscussionoftheinterfaceofpsychiatricillnessandsmoking,particularlyamongthosechronicallyhospitalizedinpsychiatricinstitutions.Itsuggestsarationalapproachtohelppsychpatientsstopsmoking.

Clinicaldatasuggestthatsmokinginschizophreniaisanattempttoself-medicate(negative)symptoms.Knowledgeontheeffectsofnicotineonschizopatientsmayleadtonewtreatmentforbothdxandtx.

Investigatedthreecomponentsofthesocial-scientific-ethicaldilemmathatresearcherslookingintothepossibletherapeuticeffectsandthemechanismsofactionofnicotineinneuropsychiatricdisorders.

Reviewof24empiricalstudiesofoutcomesofsmokingcessationapproachesusedwithsamplesofpersonswithmentaldisorders.Foundthatthemajorityofinterventionscombinedmedicationandpsychoeducation.

ThisarticlefoundthatbupropionSRappearstobeasafe,well-toleratedandeffectivemedicationincombinationwithsmokingcessationcounsellingforawiderangeofsmokers.

Exploretheuniquecircumstancesofpsychiatricpatients,therelationshipbetweenpsychiatricdisorderandnicotineaddition,andspecialproblemsinpsychiatricinstitutions/recentresearchontheinteractionbetweensmokingcessation,relapse,andmooddisorderisreviewed/discussesinteractionbetweenpsychotropicmedicationsandsmoking.

Empiricalliteratureontheeffectivenessofcombinedtreatmentofspecificsubstanceusedisorders.Reviewof3oftheleadingpsychotherapiescurrentlyinuseinthetreatmentofpatientswithsubstanceabusedisorders:12-step,motivationalenhancementtherapy,andrelapseprevention.

Pharmacotherapiescanbeintegratedwithbehavioralmanagementtechniquesthatareindividualizedtotheneedsofthepatient.


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These materials are funded with proceeds from Colorado’s tobacco tax.

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