How to treat nicotine dependence in smokers with schizophrenia
Improve patients’ health, help them kick addiction with this practical approach.
NRT in a variety of delivery forms has been well tolerated and modestly effective for smoking cessation in schizophrenia.23,27,28 Combinations of short-acting NRT (gum, lozenge, inhaler, or nasal spray) with the long-acting NRT patch improve long-term abstinence rates in smokers in the general population26 and may improve abstinence rates in those with schizophrenia.27 Maintaining the pharmacotherapy used to achieve abstinence may also improve sustained abstinence rates.
Varenicline is a partial nicotinic receptor agonist approved for treating tobacco dependence. No reports have been published on its safety and efficacy for smoking cessation in persons with schizophrenia.
In our experience with open-label varenicline for nicotine dependence in schizophrenia, 8 of 9 patients quit smoking, reported reduced cravings, and remained clinically stable on the agent for 6 to 9 months. All had previously relapsed after discontinuing NRT, bupropion, or the combination.
Controlled trials are needed to discern this agent’s place in the treatment hierarchy for smokers with schizophrenia, and several such trials are underway.
10-step office-based approach
CBT alone is not effective for smoking cessation in the schizophrenia population,22,28 but pharmacologic interventions have not been shown to succeed without concurrent behavioral treatment.
The 10 behavioral treatments described below and the tools listed in Table 3 can be covered in 1 or 2 visits and individualized for a relatively brief, office-based approach. Using the complete list may be ideal, but you can deliver a reasonable behavioral intervention by choosing tasks tailored to each patient’s needs. After the initial session, review these interventions at follow-up appointments to reinforce skills.
1 Send a clear and simple message to your patients to quit smoking. If possible, provide a handout about health risks of smoking and benefits of quitting.
2 Elicit the patient’s reasons for wanting to quit, and help him or her list these reasons as specifically as possible, such as:
- “I want to have more spending money.”
- “I want to improve my health.”
- “I want to make my sister proud.”
3 Prescribe pharmacotherapy, as supported by clinical trial results. Explain the rationale for its use, and encourage adherence. Review proper techniques for using NRT patches and gum, lozenge, inhaler, or nasal spray.
4 Teach the patient skills to cope with cravings. The “4 Ds” are a helpful mnemonic:
- Deep breathe.
- Drink fluids.
- Delay (smoking).
- Do something else.
5 Discuss the patient’s smoking triggers and risky situations. These vary from patient to patient, but common triggers include:
- finishing a meal or drinking coffee
- seeing other people smoking
- psychological stressors or psychiatric symptoms such as anxiety or auditory hallucinations
- boredom, such as waiting for a bus.
- going to a day treatment center where most patients and staff smoke
- visiting a family member who smokes
- dealing with a stressful situation.
6 Set a quit date with a detailed “quit day” plan. When the patient has some mastery over triggers and risky situations, work with him or her to prepare for quit day (such as throw out cigarettes and lighters, tell family he or she will be quitting).
Plan the day, often hour by hour, to help the patient make new choices (such as go to the park in the morning instead of the convenience store, do a puzzle while watching TV at night). Schedule in some rewards and pleasant activities to substitute for cigarettes.
7 Work on ‘refusal skills.’ Patients will likely need to practice saying no to cigarettes offered to them in their social environments. Discuss these skills, and role-play to increase patients’ likelihood of success.
