How—and why—to help psychiatric patients stop smoking

Scant data support the myth that smoking cessation worsens psychiatric symptoms. For example, in a review on tobacco dependence and schizophrenia, George et al² concluded that the effects of smoking cessation on schizophrenia symptoms are not clear. Two smoking cessation trials in schizophrenic patients treated with nicotine patches found no significant changes in postcessation psychotic symptoms.^17,18

Concerns that substance-abusing patients should not attempt to quit smoking during alcohol and other drug dependence treatment are also unsubstantiated. Rather than exacerbating drug addiction, smoking cessation has been found to improve addicts’ abstinence rates.¹⁹

USING AVAILABLE THERAPIES

Evidence is insufficient so far to show whether psychiatrically ill smokers would benefit more from specially tailored cessation treatments than from standard treatments, according to the 2000 U.S. Public Health Service clinical practice guide.¹² Thus, while researchers try to resolve this issue, psychiatrists are left to use medications found to be effective in smokers overall.

Clinical vignette. Mr. J, age 45, has paranoid-type schizophrenia and has been smoking at least two packs of cigarettes daily for 25 years. He complains of a productive cough and expresses interest in quitting smoking when his psychiatrist raises this topic.

His persecutory delusions are well-controlled on olanzapine, 10 mg/d. He is adhering with his medications and participating in weekly group counseling that provides supportive therapy for patients with serious mental illness.

In this schizophrenic smoker who is willing to try to quit, the psychiatrist performed the first three of “5 ‘A’s” (Table 2) of brief clinical intervention for tobacco dependence.^5,12 The next steps are to assist the patient’s effort to quit and arrange follow-up.

When to quit. The best time for a smoker with psychiatric illness to try to quit is when he or she:

• is psychiatrically stable
  
• is not in crisis
  
• has no recent or planned psychiatric drug changes.
  

Smoking cessation may increase blood levels of these psychotropics

Olanzapine’s clearance is approximately 40% higher in smokers than in nonsmokers. The psychiatrist discussed this with Mr. J and:

• asked him to call if side effects develop during the quit attempt
  
• scheduled more-frequent appointments to monitor side effects.
  

Mr. J’s schizophrenia is stable on maintenance therapy with an atypical antipsychotic. Schizophrenic smokers taking atypicals may be more able to quit smoking with NRT or sustained-release bupropion, compared with those taking conventional antipsychotics.²

The psychiatrist also determined that Mr. J had tried to quit smoking three times. Two of these attempts were done “cold turkey,” without pharmacotherapy, and one involved using nicotine gum. Mr. J said that although the gum “worked well at first,” he stopped using it because it was expensive and made his mouth sore. This information helped the psychiatrist choose medication for this quit attempt.

Most smoking cessation guidelines rely on a stepped-care approach, progressing from minimal to more-intensive interventions as needed.⁵ Mr. J’s psychiatrist devised an intensive treatment plan because:

• Mr. J has tried to quit before
  
• schizophrenic patients generally have more difficulty quitting and are more nicotine-dependent than other smokers.
  

Table 4

Nicotine replacement and other options for smoking cessation