Smoking and Behavioral Health

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Smoking and Behavioral Health

• Steven A. Schroeder, MD University of California,
  San Francisco

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Need for smoking intervention

• Smoking cessation needs to become a higher
  priority in the behavioral health field.
• While focusing on mental health, clinicians
  sometimes miss this more deadly condition.
• Addressing tobacco can improve health, ease pain,
  and save lives.

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Background

• 44 of cigarettes smoked in the US are consumed
  by individuals with a psychiatric or substance
  abuse disorder.
• Mental health clinicians have traditionally
  chosen to allow smoking to continue, believing
  that their patients could not handle the stress
  of cessation.

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Background (2)

• Persons with mental illness are twice as likely
  to smoke as other persons.
• Roughly 60-95 of patients in addiction treatment
  are tobacco dependent.
• Of those individuals, roughly half smoke more
  than 25 cigarettes per day.

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Background (3)

• Cigarette smoking appears consistently highest
  among people with psychotic disorders, but
  remains high also for depression, anxiety,
  substance abuse, and personality disorders.
• An estimated 200,000 smokers with mental illness
  or addiction die each year due to smoking, a
  figure highly disproportionate to the number of
  those with mental disorders in the general
  population.

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Comparative Causes of Annual Deaths in the United
States
Number of Deaths (thousands)
Est. 200,000 per year for mentally ill and SA
AIDS Alcohol Motor Homicide
Drug Suicide Smoking
Vehicle
Induced
Source CDC
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Smoking and depression

• Rates of smoking are estimated at 50-60 in
  patients with a clinical diagnosis of depression.
• 25-40 of psychiatric patients seeking smoking
  cessation treatment have a past history of major
  depression or minor dysthymic disorder.

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Smoking and schizophrenia

• Patients with schizophrenia smoke at three times
  the rate of the general population.
• Some studies show prevalence rates as high as
  90.

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Smoking and schizophrenia

• Smokers with schizophrenia experience increased
  psychiatric symptoms, number of hospitalizations,
  and need for higher medication doses.
• The metabolism of tobacco (not nicotine) can
  dramatically affect psychiatric medication dosing
  requirements and blood levels by affecting the
  P450 liver cytochrome enzymes.
• Often smoking requires a doubling of medication
  dosage.

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Smoking and schizophrenia

• In addition, the effect on medication metabolism
  can be a detrimental factor when patients are
  stabilized.
• In the stabilizing setting there is little or no
  smoking, but patients can exhibit dramatically
  increased tobacco usage after they transition to
  outpatient care.
• As a result, medication blood levels may drop,
  leading to a psychiatric relapse.

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Anxiety disorders and tobacco

• The presence of an anxiety disorder with or
  without concurrent depression is associated with
  an increased likelihood of smoking.

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Anxiety disorders and tobacco (2)

• Smoking has been found to be a risk factor for
  the onset of panic disorder, and elevated smoking
  rates are observed in patients with chronic panic
  disorder.
• Despite patients subjective reports that smoking
  reduces anxiety, chronic nicotine use in animals
  is related to increased anxiety.

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Smoking and alcohol dependence

• Smokers have a 2-3 times greater risk for alcohol
  dependence than nonsmokers.
• An estimated 80 of alcoholics currently smoke.

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Smoking and alcohol dependence (2)

• More alcoholics die from smoking-related diseases
  than from alcohol- related ones.
• Both founders of Alcoholics Anonymous died from
  their tobacco addictions.

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Smoking and other substance abuse

• Smoking rates are 2-3 times higher among drug
  addicts than the general population .
• Surveys have reported 85-98 smoking prevalence
  rates in methadone maintenance program patients.

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Why is the prevalence rate so high?

• Smoking is a form of self-medicating.
• The cultures of the mental health/addiction
  communities.
• The culture of the treatment community.
• Cigarettes viewed as a friend.

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Reasons for not helping patients quit

• 1. Too busy
• 2. Lack of expertise
• 3. No financial incentive
• 4. Most smokers cant/wont quit
• 5. Stigmatizing smokers
• 6. Respect for privacy
• 7. Negative message might scare away patients
• 8. I smoke myself

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1. Too busy?

• Interventions can take as little as 30 seconds.
• No other health result could be achieved with
  such a small investment of time.
• It is the job of health professionals to help
  patients be healthier.
• Smoking cessation is basic treatment.
• Not helping smokers quit could be malpractice in
  many diseases.

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2. Lack of expertise?

• Virtually no expertise is needed to refer
  patients to a telephone quitline or website.
• Basic facts are straightforward counseling plus
  nicotine replacement therapy and/or other drugs
  can greatly help patients quit.
• The quitline or website staff provide smokers
  with all needed information.

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3. No financial incentive?

• Smoking cessation should be part of basic visit.
• Counseling may be reimbursable in many
  situations.
• Could avoid a nasty malpractice suit.

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4. Patients unlikely to quit?

• Almost a quarter of patients in one study who had
  multiple quitline sessions were abstinent after
  12 months.
• With help from a clinician, the number of
  patients who quit smoking doubles.
• Evidence suggests use of a quitline can more than
  triple success in quitting.

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5. Stigma attached to smoking?

• Most smokers get addicted in early teens.
• The most effective message is to empower smokers
  to quit You can do it.
• Nicotine is highly addictive (more addictive than
  heroin), yet thousands of smokers quit every year.

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6. Privacy for patients?

• Numerous studies show that patients, even those
  who plan to continue smoking, prefer that health
  professionals advise them to quit.
• Most smokers want to quit and want support and
  encouragement to do so, especially from those
  they highly respect and trust.

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7. Afraid of scaring off patients?

• Again, smokers want to be encouraged to quit by
  health professionals.
• Almost everyone today is aware of the health
  risks of smoking. It is perfectly natural and
  expected that a health professional will mention
  them.
• Many smokers are concerned about the effect of
  second-hand smoke on their loved ones.

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8. I smoke myself

• Health professionals also need help and support
  in quitting smoking.
• No one understands the difficulty of quitting
  more than a person who has recently quit.

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Substance abuse counselors

• Over 40 of substance abuse counselors smoke.
• 61 of the attendees at the last NAADAC
  conference smoked.
• Many counselors resist the smoking cessation
  movement because they smoke. They fear losing
  their jobs if they cant quit.

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Should health professionals steer smokers with
mental illness or addiction into cessation?

• Some are challenging the longstanding belief that
  those with mental illness or drug addiction
  cannot handle the stress of cessation.
• New evidence suggests addicts in fact do much
  better with overall recovery and resistance to
  relapse if they also quit smoking.

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Nicotine as a medication?

• There must be a better medication than nicotine.

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Question of causality

• Recent childhood and adolescent studies show that
  prior smoking was a risk factor for depression,
  not vice versa.
• In the majority of schizophrenic individuals who
  smoked, their smoking habit preceded the onset of
  their disease.

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Question of Causality (2)

• Smoking is often followed by harder drug use.
• Teens who smoke are 14 times more likely to have
  tried marijuana.
• Among regular teen marijuana users, 60 percent
  report trying cigarettes first.
• New studies show a 50 percent reduction in teen
  cigarette smoking could lead to a 16 to 28
  percent reduction in teen marijuana use.

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Cessation Will Enhance Patient Well-Being

• New findings reinforce the importance of ending
  nicotine addiction in the context of other
  addictions.
• Improved mental and physical health require
  kicking the tobacco habit.
• Smoking is the number one cause of death among
  psychiatric patients.

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Cessation Will Enhance Others Well-Being

• In addition to helping patients, smoking
  cessation treatment will improve the health of
  the smokers family and friends by reducing
  exposure to secondhand smoke.

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Secondhand smoke

• Secondhand smoke contains 4000 chemicals, 50 of
  which are known carcinogens, and 6 that
  negatively impact childhood development and
  reduce fertility in both sexes.
• More non-smokers will die from exposure to
  secondhand smoke than from any other air
  pollutant.

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Secondhand smoke (2)

• Children of parents who smoke are at a higher
  risk for developing chronic coughing, wheezing,
  and phlegm production, middle ear infections, and
  asthma.
• Infants are three times as likely to die from
  SIDS if their mothers smoked during and after
  pregnancy, and twice as likely if their mothers
  stop smoking during pregnancy but resume again
  following birth.

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Current barriers

• Not all institutions are smoke-free.
• For those institutions that are, most still allow
  smoking on the grounds.
• Staff concerns patients will be more. difficult
  to manage if they are not allowed to smoke.

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What can be done?

• Mental health and substance abuse fields need to
  embrace smoking cessation.
• Policy should be implemented for smoke-free
  institutions and grounds to reduce second-hand
  smoke exposure to non-smokers
• Offer cessation assistance to both patients and
  counselors.

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What can be done? (2)

• CO breath testing to patients for tangible
  evidence of the damage smoking is inflicting on
  their health.
• Intervention need not be onerous.
• Most smokers want to quit.
• Those with outpatient conditions can often be
  referred to quitlines.

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What are quitlines?

• Nearly every American has access to a free
  telephone service for cessation.
• Nearly 40 states sponsor quitlines, and four
  cover the nation.
• Lines are staffed by trained tobacco cessation
  counselors.
• Services are tailored for each individual, and
  they have proven at least to double efficacy.

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What about those who cant use quitlines?

• Hospitals can include cessation as part of
  treatment plan.
• After discharge, patients can continue to receive
  treatment in their aftercare plans and through
  quitlines.
• Combinations of NRT and other drugs can be
  carefully monitored.
• Therapists must care about smoking cessation

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• Thank you!
• http//smokingcessationleadership.ucsf.edu/