tobacco addiction treatment in clients with co-occurring ... · tobacco addiction treatment in...

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Tobacco Addiction Treatment in Clients with Co-Occurring

Mental Illness

Dr. Peter Selby, MBBS, CCFP, FCFP, MHSc, dipABAM, DFASAM Chief – Primary Care Division, Director of Medical Education and Clinical Scientist – Addictions, CAMH Professor, DFCM, Psychiatry, and the Dalla Lana School of Public Health, University of Toronto @drpselby www.nicotinedependenceclinic.com

Tobacco Control Symposium Nova Scotia

Sept 28th, 2018

http://www.nicotinedependenceclinic.com/

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Disclosures (5years) Grants/Research Support:

• CAMH, Health Canada, OMOH, CTCRI, CIHR, CCSA, PHAC, Alberta Health Services, • Pfizer Inc./Canada, OLA, Medical Psychiatry Alliance, ECHO, NIDA, CCSRI, CCO, OICR, • Ontario Brain Institute, McLaughlin Centre, AHSC/AFP, WSIB, NIH, AFMC, Mt Sinai Hospital,

Shoppers Drug Mart, Bhasin Consulting Fund Inc., Patient-Centered Outcomes Research Institute

Speaking Engagements (Content not subject to sponsors approval)/Honoraria:

• Pfizer Inc. Canada, Pfizer Global, ABBVie, Bristol-Myers Squibb

Consulting Fees:

• Pfizer Inc./Canada, Pfizer Global, NABI Pharmaceuticals, Evidera Inc., • Johnson & Johnson Group of Companies, Medcan Clinic, Inflexxion Inc., V-CC Systems Inc.,

MedPlan Communications, Kataka Medical Communications, Miller Medical Communications, NVision Insight Group, Sun Life Financial

Other: (received drugs free/discounted for study through open tender process) • Johnson & Johnson, Novartis, Pfizer Inc.

NO TOBACCO or ALCOHOL or FOOD INDUSTRY FUNDING

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Agenda

1. Case study

2. Screening clients with tobacco addiction and co-occurring mental illness

3. Why is it important to treat tobacco addiction in smokers with co-occurring disorders

4. Benefits of cessation in smokers with co-occurring disorders

5. Treatment options for smokers with co-occurring disorders

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Introducing Laura

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Introducing Laura

• Laura is a 36 year old single woman

• Works as a financial advisor at a bank, often works 10-12 hours/day

• Laura describes herself as very stressed, but she does not have time for self-care

• Laura has come to see you for help with her tobacco dependence

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Introducing Laura

• On review of her medical chart you notice the following:

– Laura has been smoking 25 cigarettes/day for 12 years

– Time to first cigarette is 5 minutes

– Longest quit period is 3 months 30 years old

– Tried NRT in the past

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Case study: Laura

Why can’t Laura quit tobacco smoking?

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Case study: Laura

• Psychological trauma at the age of 12

• Diagnosed with depression at age 23

• Drinks 3 glasses of wine daily during the week to unwind from work, and 9 drinks on the weekend (wine and liquor)

• Laura smokes cigarettes at work to take a “break”

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Clustering of mental health + addiction + tobacco

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Screening clients with tobacco addiction and co-occurring mental illness

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What can we do to optimize Laura’s outcomes?

• Engagement

• Focus (diagnostic overshadowing)

• Elicit

• Plan

• BioPsychoSocial Intervention

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Elements of Assessment

• Trauma History (ACE score)

• Stability

• Risk

• Meds

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Association between Tobacco Use and Co-Occurring Disorders

Drug/Stimuli Vector

Host

Environment

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Environmental

Social

Psychological

Biological

Biopsychosocial Model

BEHAVIOUR

Single model approach insufficient!!!!!

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• Mesolimbic Pathway: – Dopamine (DA) released from the VTA travels to the NAc and PFC, resulting

in feelings of reward from substance use (such as cocaine).

– DA can also extend into brain regions, including amygdala, hippocampus and orbitofrontal cortex, which are involved in executive function, emotional memory and motivation.

Pathways involved in Addiction

Volkow et al., 2012

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Adverse Childhood Experience (ACE) Study

Sample Size (N)

% Prevalence Odds Ratio

(95% CI)

Depression N = 542 50.7% vs. 14.2%1

(N = 3 799) 4.6*

(3.8 – 5.6)

Ever Attempted Suicide

N = 544 18.3% vs. 1.2%1

(N = 3 852) 12.2*

(8.5 – 17.5)

Alcoholism N = 540 16.1% vs 2.9%1

(N = 3841) 7.4 *

(5.4 – 10.2)

Current Smoker N = 544 16.5% vs. 68%1

(N = 3 836) 2.2*

(1.7 – 2.9)

Ever using Illicit Drugs

N = 541 28.4% vs 6.4%1

(N = 3856) 4.7 *

(3.7-6.0)

Injecting Drugs N = 540 3.4% vs 0.3%1

(N = 3855) 10.3 *

(4.9 – 21.4)

1individuals reporting 0 exposures to adverse childhood experience

Adults reporting exposure to 4 or more adverse childhood experiences including abuse (psychological, physical and sexual) and household dysfunction (substance abuse, mental illness, mother treated violently, and criminal behaviour in household) display increased

prevalence of health risk behaviour and disease.

Adults reporting 4 or more adverse childhood exposures vs. 0 exposure

*p < 0.001

Felitti et al., 1998

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Adverse Childhood Experience (ACE) Questionnaire

While you were growing up, during your first 18 years of life:

1. Did a parent or other adult in the household often …

Swear at you, insult you, put you down, or humiliate you?

or

Act in a way that made you afraid that you might be physically hurt?

Yes No If yes enter 1 ________

2. Did a parent or other adult in the household often …

Push, grab, slap, or throw something at you?

or

Ever hit you so hard that you had marks or were injured?


3. Did an adult or person at least 5 years older than you ever…

Touch or fondle you or have you touch their body in a sexual way?

or

Try to or actually have oral, anal, or vaginal sex with you?


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4. Did you often feel that …

No one in your family loved you or thought you were important or special?

or

Your family didn’t look out for each other, feel close to each other, or support each other?


5. Did you often feel that …

You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you?

or

Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?


6. Were your parents ever separated or divorced?


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7. Was your mother or stepmother:

Often pushed, grabbed, slapped, or had something thrown at her?

or

Sometimes or often kicked, bitten, hit with a fist, or hit with something hard?

or

Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?


8. Did you live with anyone who was a problem drinker or alcoholic or who used street drugs?


9. Was a household member depressed or mentally ill or did a household member attempt suicide?


10. Did a household member go to prison?


Now add up your “Yes” answers: _______ This is your ACE Score

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Association between ACEs and Negative Outcomes

https://www.cdc.gov/violenceprevention/acestudy/ace_brfss.html

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Why is it important to treat tobacco addiction in smokers with co-occurring disorders?

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The Relationship between Tobacco use and Co-occurring Disorders

Individuals with mental illness are more likely to have:

Earlier age of onset for tobacco use

Greater tobacco use and higher tobacco dependence • Account for 44.3% of cigarettes smoked in North

America

Co-morbid diseases caused or worsened by tobacco use (i.e. COPD, diabetes, cancer etc.)

Lasser et al., 2000; De Leon & Diaz, 2005; Canadian Mental Health Association, 2008; Solty et al., 2009; McClave et al., 2010; Aubin et al., 2012.

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Tobacco and Depression

• 60% of individuals with history of depression are current/past smokers

• Past history of MDD associated with:

• Higher prevalence of nicotine dependence

• Increased nicotine withdrawal severity

• Greater depressive symptoms during withdrawal

• Negative mood during quit attempt and higher risk of major depressive episode

• Lower long-term cessation

Individuals with MDD are approximately twice as likely to become smokers

Kalman et al. 2005; Ziedonis et al. 2008; Lasser et al. 2009; Bolam et al. 2011; Gierisch et al. 2012; Torres et al. 2010; Weinberger et al. 2013;

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Depressive Symptoms Worsen, Worsened by Cessation Attempts

Depressive symptoms Smoking cessation

Bakhshaie et al., 2015; Bolam et al., 2011; Cinciripini et al., 2003; Gierisch et al., 2012; Reid et al., 2016; Torres et al., 2010; Weinberger et al., 2013

Individuals with history of depression are current or past smokers 60%

Negative mood

Nicotine dependence

Withdrawal

Reduced likelihood of cessation success

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Positive Association: Suicide Risk and Nicotine Dependence

Substance-related factors increasing risk of suicidal thoughts or attempts

Nicotine dependence

Multiple substance use

Withdrawal during quit attempt

Intoxication

Smoking Suicide

?

?

Relationship between smoking and suicide

unclear:

Hughes, 2008; Barker et al., 2015

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Increased rates of tobacco use vs general population

• 1/3 of individuals with social anxiety disorder display ND

• Greater perceived barriers to quit

• Higher rates of relapse

False conception that smoking relieves anxiety

• Nicotine is a stimulant increases anxiety

• Confuse withdrawal with anxiety symptoms

• Quitting tobacco can improve symptoms of anxiety

Anxiety Disorders and Tobacco Use

Moylan et al., 2012; McDermott et al., 2013; Langdon et al., 2016

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Reasons/ Motivation to Quit

• Smoking cessation can reduce anxiety and depression and increase positive mood

• Depressed smokers may benefit from mood management

• Despite limited literature, treatment with bupropion, varenicline and NRT show efficacy in long-term cessation outcomes for clients with mood disorder

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Benefits of cessation in smokers with co-occurring disorders

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Change in mental health after smoking cessation: systematic review and meta-analysis

Follow-up Measure Number of Studies (N)

SMD (95% CI)

7wk – 12 m follow-up

Anxiety N = 4 studies -0.37* (-0.70 to -0.03)

3m – 6 year follow up

Mixed anxiety and depression

N = 5 studies -0.31* (-0.47 to -0.14)

11wk – 5 year follow-up

Depression N = 10 studies -0.25* (-0.37 to -0.12)

6m – 6 year follow-up

Stress N = 3 studies -0.27* (-0.40 to -0.13)


Psychological Quality of Life

N = 8 studies 0.22* (0.09 to 0.36)


Positive Affect N = 3 studies 0.40* (0.09 to 0.71)

Change in mental health from baseline to follow-up in smokers who quit vs continued smokers

*Significant at p < 0.05

Taylor, Gemma et al., 2014

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Change in mental health after smoking cessation: systematic review and meta-analysis

Smoking cessation is associated with REDUCED anxiety, depression and stress, and IMPROVED psychological quality of

life, and positive affect.

Taylor, Gemma et al., 2014

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Treatment options for smokers with co-occurring disorders

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Psychosocial Interventions

Motivational Interviewing (MI) Psychoeducation Cognitive Behavioural Therapy (CBT)

Relaxation and Mindfulness Social Support Group Therapy

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Pharmacological Interventions

Bupropion

Varenicline

NRT

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EAGLES: Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in

smokers with and without psychiatric disorders

Population

Intervention 12 week

treatment – 12 week non treatment

% Abstinence Rate +

OR (95%CI) (week 9-12)

% Abstinence Rate +

OR (95% CI) (week 9-24)

What does this mean?

- Smokers age 18-75 years - DSM IV criteria for mood disorder - > 10 cpd

Varenicline 1 mg twice/day

(n = 1026) vs Placebo

(n = 1015)

29.2% vs 11.4 % 3.24*

(2.56 – 4.11)

18.3% vs 8.3% 2.50*

(1.90 – 3.29)

Smokers with psychiatric

disorder treated with varenicline, bupropion and

NRT show significantly

greater odds of continuous

smoking abstinence

compared to placebo group.

Bupropion 150 mg twice/day

(n = 1017) vs Placebo

(n = 1015)

19.3% vs 11.4% 1.87*

(1.46 – 2.39)

13.7% vs 8.3% 1.77*

(1.33 – 2.36)

NRT 21 mg per day (n = 1016) vs

Placebo (n = 1015)

20.4% vs 11.4% 2.00*

(1.56 – 2.55)

13.0% vs 8.3% 1.65*

(1.24 – 2.20)

Anthenelli RM, et al., 2016 *Significant at p<0.05

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Treatment with varenicline showed the greatest efficacy in maintaining continuous abstinence rates in smokers with psychiatric disorders compared to bupropion, NRT

and placebo groups.

Anthenelli RM, et al., 2016

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Tobacco Interventions and for Individuals with Depression

Meta-analysis: Effectiveness of smoking cessation interventions, with and without specific mood management components, in smokers with current or past depression

Number of trials (N)

Risk Ratio (95% CI) What does this mean?

Psychosocial Mood

Management vs Control

11 Trials (N = 1844)

current depression

1.47* (1.13, 1.92) Adding psychosocial mood

management to standard smoking cessation intervention, compared

to standard intervention alone, had a positive effect on increasing

cessation in smokers with current or past depression.

13 Trials (N = 1496)

past depression

1.41* (1.13, 1.77)

Outcome: Abstinence at 6 month follow up or longer; *significant at p < 0.05

van der Meer et al., 2013

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Tobacco Interventions and for Smokers with Depression


Number of Trials (N)

Risk Ratio (95% CI)

What does this mean? Limitation

Bupropion (150 - 300 mg)

vs Placebo

5 Trials (N = 410) current

depression

1.37 (0.83, 2.27)

Treatment with bupropion may have a significant effect

on long-term cessation in smokers with past

depression compared to placebo.

Evidence for significance is weak due to

limited number of

studies

4 Trials (N = 404)

past depression

2.04* (1.31, 3.18)

Outcome: Abstinence at 6 month follow up or longer; *significant at p < 0.05


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Tobacco Interventions and for Individuals with Depression


Number of Trials

(N)

Risk Ratio (95% CI)

What does this mean? Limitation

NRT vs Placebo

1 Trial (N = 196) current

depression

2.64 (0.93, 7.45)

Treatment with NRT shows a positive (but not

significant) effect on long-term cessation in smokers

with current and past

depression compared to placebo.

Evidence is weak due to limited

number of studies.

3 Trials (N = 432)

past depressio

n

1.17 (0.85, 1.60)

Outcome: Abstinence at 6 month follow up or longer.


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Effect of Nicotine Patches on Cessation in Smokers with Self-reported Depression or Anxiety

Life-time diagnostic status of depression/anxiety does not influence quit outcome

when NRT is mass distributed for a 5-week

course

Kushnir et al., 2016

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Effect of Nicotine Patches on Cessation in Smokers with Self-reported Depression or Anxiety

Life-time diagnostic status of depression/anxiety does not influence quit outcome

when NRT is mass distributed for a 5-week

course

Kushnir et al., 2016

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Tobacco Interventions for Individuals with Bipolar Disorder

Population Intervention Control Outcome

- Male or female outpatient - 18-65 years - Any race -DSM-IV bipolar disorder - > 10 cpd - No pharmacotherapy

N = 31 12 weeks treatment + 12 weeks follow-up Prescribed varenicline; - 0.5 mg once/day for 1-3 days - 0.5 mg twice/day for 4-7 days - 1mg twice/day for remainder of 12 weeks

N = 29 Placebo – same schedule as varenicline

At the end of 12 week treatment, varenicline

group significantly more likely to achieve 7-day PPA (OR = 8.13; 95% CI: 2.03 – 32.53)

And 4-week continuous abstinence

(OR = 4.77; 95% CI: 1.02 – 25.13)

compared to placebo.

Chengappa et al. 2014

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Tobacco Interventions for Individuals with PTSD

Population Intervention Control Outcome

- PTSD outpatient treatment program - DSM-IV criteria for PTSD - 15 male combat veterans - 47-58 years old (Mage = 50) - 60% Caucasian, 40% minority

N = 10 12 weeks treatment Prescribed bupropion SR; -150 mg once/day for 3-4 days - 150 mg twice/day remainder - Received individual counselling sessions

N = 5 Received placebo + individual counselling sessions

At the end of week 8, patients receiving bupropion SR more successful at achieving cessation vs placebo group (70% vs 20%) At 6 month follow-up, greater proportion of patients in bupropion SR group maintained cessation vs placebo group (40% vs 20%)

Hertzberg et al. 2001

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Tobacco Interventions for Individuals with Schizophrenia

Number of Trials (N)

Risk Ratio (95% CI)

What does this Mean?

Bupropion (150 – 300 mg)

vs. Placebo

End of Treatment 7 studies N = 340

3.03* (1.69 – 5.42)

Treatment with bupropion significantly increased smoking cessation rates at the end of

treatment, and at 6 month follow-up, compared to placebo, in patients with

schizophrenia. Treatment with bupropion did not result in adverse events or changes in mental state (including positive, negative or depressive

symptoms).

6 Month Follow-Up 5 studies N = 214

2.78* (1.02 – 7.58)

Varenicline (0.5 – 1 mg) vs. Placebo

2 studies N = 137

4.47* (1.34 – 16.71)

Treatment with varenicline significantly increased smoking cessation rates at the end of

treatment, compared to placebo, in patients with schizophrenia.

However adverse psychiatric events, including suicidal ideation and behaviour, were reported

in 2/144 patients using varenicline .

Tsoi et al., 2013

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Tobacco Interventions for Individuals with Alcohol Use Disorder (AUD)

Considerations for Prescribers: • Varenicline may reduce alcohol consumption; however more research needed

to verify efficacy

• Combination treatment with NRT and bupropion does not appear to be more effective for individuals with AUD

• Naltrexone may be used to reduce alcohol cravings, and may also reduce weight gain

• Individuals should meet the following criteria before using bupropion

– No current risk of seizures

– In treatment for alcohol use disorder

– Alcohol use is stable

– Should not drink > 2 standard drinks/day

Nicotine patches, bupropion and varenicline appear to be effective treatment options for individuals with concurrent tobacco and alcohol dependence.

Hughes et al., 2003; King et al., 2013; Nocente et al., 2013;

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Review the Case: Laura

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Drug Interactions Antidepressant Class Names of Medications Potential Drug Interactions

Selective Serotonin Reuptake Inhibitors (SSRI)

citalopram (Celexa), fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft)

St. John’s Wort, MAOI; alcohol can increase side effects; caffeine can increase anxiety/insomnia

Anxiolytic Class Names of Medications Potential Drug Interactions

Benzodiazepines alprazolam (Xanax), bromazepam (Lectopam), chlordiazepoxide (Librium), Clonazepam (Rivotril), diazepam (Valium), flurazepam (Dalmane), lorazepam (Ativan), nitrazepam (Mogadon), oxazepam (Serax), temazepam (Restoril), triazolam (Halcion)

Alcohol can increase side effects, especially drowsiness; use with caution in combination with other CNS drugs – can cause increased sedation and other side effects

https://www.nicotinedependenceclinic.com/English/teach/SiteAssets/Pages/Special-Populations

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Drug Interactions Antipsychotics Names of Medications Potential Drug Interactions

First Generation (Typical, Conventional) Antipsychotics

chlorpromazine (Largactil), flupenthixol (Fluanxol), fluphenazine (Modecate), fluspirilene (IMAP), haloperidol (Haldol), loxapine (Loxapac), mesoridazine (Serentil), pericyazine (Neuleptil), perphenazine (Trilafon), pimozide (Orap), pipotiazine (Piportil), prochlorperazine (Stemetil), thioridazine (Mellaril), thiothixene (Navane), trifluoperazine (Stelazine), zuclopenthixol (Clopixol)

alcohol can increase side effects; caffeine can increase anxiety and agitation; use with caution in combination with other CNS drugs, which can increase side effects

Second Generation (Atypical, Novel) Antipsychotics

clozapine (Clozaril), olanzapine (Zyprexa, Zyprexa Zydis), quetiapine (Seroquel), risperidone (Risperdal, Risperdal M-TAB)

alcohol can increase side effects; caffeine can increase anxiety and agitation; use with caution in combination with other CNS drugs, which can increase side effects

https://www.nicotinedependenceclinic.com/English/teach/SiteAssets/Pages/Special-Populations

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Drug Interactions with Tobacco Smoke

Drug/Class Mechanism of Interaction and Effects

Alprazolam (Xanax) Possible decrease plasma concentrations

Caffeine Increased metabolism (induction of CYP1A2); increased clearance (56%). Caffeine levels likely increase after cessation

Clozapine (Clozaril) Increased metabolism (induction of CYP1A2); decreased plasma concentrations (by 18%). Increased levels upon cessation may occur; closely monitor drug levels and reduce dose as required to avoid toxicity

Benzodiazepines Decreased sedation and drowsiness, possibly caused by nicotine stimulation of CNS

Serotonin 5-HT1 receptor agonists (triptans)

This class of drugs may cause coronary vasospasm; caution for use in smokers due to possible unrecognized CAD

TEACH/MISUD/Drug Interactions with Smoking TABLE.pdf

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Summary

• Individuals with mental illness and substance use disorder display higher prevalence of nicotine dependence and lower long-term cessation

• Smoking cessation can reduce anxiety and depression and increase positive mood

• Despite limited literature, treatment with bupropion, varenicline and NRT show efficacy in long-term cessation outcomes for clients with co-occurring mental illness and substance use disorder

• Healthcare providers should offer a combination of counselling and pharmacotherapy treatment to individuals with mental illness and/or substance use disorder.

Questions

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References • American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders. (4th Text

Revision ed.) Washington, DC: American Psychiatric Association.

• Anthenelli, RM., Benowitz, NL., West, R., Aubin. LS., McRae, T., Lawrence, D., Ascher, J., Russ, C., Krishen, A., Evins, AE., 2016. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomized, placebo-controlled clinical trial. The Lancet, 387: 2507-2520

• Bolam B, West R, Gunnell D. Does smoking cessation cause depression and anxiety? Findings from the ATTEMPT cohort. Nicotine & Tobacco Research : Official Journal of the Society for Research on Nicotine and Tobacco. 2011;13(3):209-214./

• Chengappa KN, et al. (2014). Varenicline for smoking cessation in bipolar disorder: A randomized, double-blind, placebo-controlled study. The Journal of Clinical Psychiatry, 75(7), 765-772.

• Centers for Disease Control and Prevention. About Behavioural Risk Factor Surveillance System ACE Data. https://www.cdc.gov/violenceprevention/acestudy/ace_brfss.html

• Gierisch JM, Bastian LA, Calhoun PS, et al. Smoking cessation interventions for patients with depression: A systematic review and meta-analysis. Journal of General Internal Medicine. 2012;27(3):351-360.

• Hertzberg MA, et al. (2001). A preliminary study of bupropion sustained-release for smoking cessation in patients with chronic posttraumatic stress disorder. Journal of Clinical Psychopharmacology, 21(1), 94-98.

• Kalman D, Morissette SB, George TP. Co-morbidity of smoking in patients with psychiatric and substance use disorders. The American Journal on Addictions / American Academy of Psychiatrists in Alcoholism and Addictions. 2005;14(2):106-123.

• Kushnir, V., Menon, M., Balducci, X.L., Selby, P., Usoa B., Zawertailo, L.(2013). Enhanced smoking cue salience associated with depression severity in nicotine-dependent individuals: a preliminary fMRI study. Int J Neuropsychopharmacol.16 (5): 997-1008. doi: 10.1017/S1461145710000696

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References (cont’d) • Kushnir V, Sproule BA, Zawertailo L, et al. (2016). Impact of self-reported lifetime depression

or anxiety on effectiveness of mass distribution of nicotine patches. Tob Control. Published Online First: 19 August 2016. doi: 10.1136/tobaccocontrol-2016-052994

• Langdon K.J., Farris S.G., Hogan J.B.D., Grover K.W., Zvolensky M.J. (2016). Anxiety sensitivity in relation to quit day dropout among adult daily smokers recruited to participate in a self-guided cessation attempt. Addict Behav. (58): 12 – 15.

• Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness: A population-based prevalence study. JAMA: the Journal of the American Medical Association. 2000;284(20):2606-2610.

• Moylan, S., Jacka, F. N., Pasco, J. A., & Berk, M. (2012). Cigarette smoking, nicotine dependence and anxiety disorders: A systematic review of population-based, epidemiological studies. BioMed Central (BMC) Medicine, 10(1), 123-137

• McDermott, M. S., Marteau, T. M., Hollands, G. J., Hankins, M., & Aveyard, P. (2013). Change in anxiety following successful and unsuccessful attempts at smoking cessation: Cohort study. The British Journal of Psychiatry, 202(1), 62-67.

• TEACH. (2017). Tobacco Interventions for Clients with Mental Illness and/or Substance Use Disorders. Retrieved from the Centre for Addiction and Mental Health course website: https://courses.camh.net/d2l/le/news/9284/11743/view; https://www.nicotinedependenceclinic.com/English/teach/SiteAssets/Pages/Special-Populations/Psychiatric%20Medication%20Tables.pdf

https://courses.camh.net/d2l/le/news/9284/11743/view

https://courses.camh.net/d2l/le/news/9284/11743/view

https://www.nicotinedependenceclinic.com/English/teach/SiteAssets/Pages/Special-Populations/Psychiatric Medication Tables.pdf



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References (cont’d) • Taylor G., McNeil A., Girling A., Farley A., Lindson-Hawley N., Aveyard P. (2014) Change in

mental health after smoking cessation systematic review and meta-analysis. BMJ 348:g1151.

• Torres LD, Barrera AZ, Delucchi K, et al. Quitting smoking does not increase the risk of major depressive episodes among users of Internet smoking cessation interventions. Psychological Medicine. 2010;40(3):441-449

• van der Meer, RM., Willemsen, MC., Smit, F., Cuijpers, P. (2013). Smoking cessation interventions for smokers with current or past depression (Review). The Cochrane Library, 2013 (8), 1-134.

• Weinberger AH, Mazure CM, Morlett A, et al. Two decades of smoking cessation treatment research on smokers with depression: 1990-2010. Nicotine & Tobacco Research : Official Journal of the Society for Research on Nicotine and Tobacco. 2013;15(6):1014-1031.

• Zawertailo, L., Voci, S., Selby, P. (2015). Depression status as a predictor of quit success in a real world effectiveness study of nicotine replacement therapy. Psychiatry Res. 226; 120-127.

• Zawertailo, L., Baliunas, D., Ivanova, A., Selby P.L. (2015). Individualized treatment for tobacco dependence in addictions treatment settings: the role of current depressive symptoms on outcomes at 3 and 6 months.

• Ziedonis D, Hitsman B, Beckham JC, et al. Tobacco use and cessation in psychiatric disorders: National Institute of Mental Health report. Nicotine & Tobacco Research: Official Journal of the Society for Research on Nicotine and Tobacco. 2008;10(12):1691-1715.

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