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Treating Nicotine Dependence in Smokers with Mental Illness and Chemical Dependencies. Lirio S. Covey, Ph.D. David Kalman, Ph.D. Taru Kinnunen, Ph.D. Kimber Richter, Ph.D. Jill M. Williams, M.D. Nancy Kaufman, M.A. Today’s Goals. The nature of nicotine dependence

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slide1

Treating Nicotine Dependence in Smokers with Mental Illness and Chemical Dependencies

Lirio S. Covey, Ph.D.

David Kalman, Ph.D.

Taru Kinnunen, Ph.D.

Kimber Richter, Ph.D.

Jill M. Williams, M.D.

Nancy Kaufman, M.A.

today s goals
Today’s Goals
  • The nature of nicotine dependence
  • Nicotine dependence and psychiatric co-morbidity
  • Smoking cessation and psychiatric disorders
  • Treatments
today s goals1
Today’s Goals
  • The nature of nicotine dependence
  • Nicotine dependence and psychiatric comorbidity
  • Smoking cessation and psychiatric disorders
  • Treatments
the long standing view tobacco use is a health risk factor
The long-standing view: Tobacco Use Is a Health Risk Factor
  • Cardiovascular disease
  • Cancer of multiple organ sites
  • Pulmonary Disorders
  • Fetal/infant/childhood morbidity & mortality through second-hand smoke
evolved view tobacco use is a more than a risk factor
Evolved view:Tobacco Use Is a More than a Risk Factor

Tobacco use, in particular, chronic use of tobacco, is a disorder in itself.

slide7

Nicotine Is a Drug: Neurochemical Effects of Nicotine

DOPAMINE

Pleasure, Appetite Suppression

NOREPINEPHRINE

Arousal, Appetite Suppression

ACETYLCHOLINE

Arousal, Cognitive Enhancement

NICOTINE

Mood Appetite suppression

SEROTONIN

VASOPRESIN

Memory Improvement

BETA-ENDORPHIN

Reduction of Anxiety, Tension

today s goals2
Today’s Goals
  • The nature of nicotine dependence
  • Nicotine dependence and psychiatric disorders
  • Smoking cessation and psychiatric disorders
  • Treatments – what works?
slide10

Higher prevalence of tobacco use

among persons with mental illness.

slide11

Multiple mental disorders are involved:

Alcohol and drug dependence

Depression

Anxiety disorders (GAD, phobias, PTSD)

Schizophrenia

  • Antisocial personality disorder
  • Conduct disorder and ADHD
smoking and mental illness lasser k et al jama 2000
Smoking and Mental Illness, Lasser K et al, JAMA, 2000
  • In the U.S., 20% have a lifetime history of a medical condition
  • 44% of all cigarette smoking done by persons with lifetime history of mental illness.
slide13

Current Smokers by Mental Illness

History, Lasser et al, JAMA, 2000

%

41.0

34.8

22.5

None Ever Ill Past Month

prevalence of current smoking lasser jama 2000
Prevalence of Current SmokingLasser, JAMA, 2000

%

16.9 21.5 11.4 0.6 50.7

Per cent prevalence of the condition in US population

prevalence of current smoking lasser jama 20001
Prevalence of Current SmokingLasser, JAMA, 2000

%

4.8 6.4 11.0 6.5 50.7

Percent prevalence of the condition in the US population

slide17

Major Depression

Alcohol Dependence

Drug Dependence

Schizophrenia

major depression
Major Depression
  • More smokers among depressed persons
  • More depression among smokers
  • Higher nicotine dependence level
    • Often smoke more cigarettes
    • Harder time quitting
    • More intense withdrawal symptoms
  • Treatments
eversmoking by mdd hx and gender st louis eca n 3213
Eversmoking by MDD hx and genderSt. Louis ECA (n=3213)

p<.001

p<.001

%

Glassman, et al, JAMA, 1990

odds ratios for psychiatric diagnoses by nicotine dependence 1200 adults 21 30 yrs
Odds ratios for psychiatric diagnoses by nicotine dependence ,1200 adults, 21-30 yrs

Substance Dep

MDD

Anxiety

Breslau et al, 1992

major depression1
Major Depression
  • More smokers among depressed persons
  • More depression among smokers
  • Higher nicotine dependence level
    • Often smoke more cigarettes
    • Harder time quitting
    • More intense withdrawal symptoms
  • Treatments
influence of depression history on one year cessation week 52 by treatment
Influence of Depression History on One Year Cessation (Week 52) by Treatment

Smith, Nicotine & Tobacco

Research 2003

incidence of major depressive episodes in 3 month follow up of 126 abstinent smokers
Incidence of major depressive episodes in 3-month follow-up of 126 abstinent smokers

p=<.001,

Covey et al, Am J Psychiatry, 1997

nicotine withdrawal symptoms intensity at week 1 after quit day
Nicotine withdrawal symptoms: intensity at week 1 after quit day

p<.05

p<.01

craving

irritable

anxious

restless

appetite

concentr

depressed

Covey et al, Comp Psychiatry,1991

major depression2
Major Depression
  • More smokers among depressed persons
  • More depression among smokers
  • Higher nicotine dependence level
    • Often smoke more cigarettes
    • Harder time quitting
    • More intense withdrawal symptoms
  • Treatments
treatments that work for smokers with major depression
Treatments that work for smokers with Major Depression
  • Bupropion (Zyban)
  • Nortriptyline
  • Nicotine replacement
  • Mood-oriented Cognitive Behavioral Therapy
long term quit rates among smokers with past mdd
Long-term quit rates among smokers with past MDD

33%

29%

15%

15%

8%

6%

Smith et al, 2003 Hall et al, 1998 Kinnunen et al, 2003

slide28

Recommendations

  • Smokers with past major depression can quit.
  • They will need more intensive and, possibly, longer treatments.
  • More information is needed for smokers

who are currently depressed.

alcohol dependence
Alcohol Dependence
  • Higher rates of current smoking
  • In clinical settings, 85% to 90% are smokers
  • Many want to quit (up to 100% in one clinical study)
    • Quit rates in recovering groups same as nonalcoholics
    • Quit rates in active drinkers lower than in nonalcoholics
  • No evidence of relapse to drinking upon tobacco abstinence
alcohol dependence1
Alcohol Dependence
  • Higher rates of current smoking
  • In clinical settings, 85% to 90% are smokers
  • Many want to quit (up to 100% in one clinical study)
    • Quit rates in recovering groups same as nonalcoholics
    • Quit rates in active drinkers lower than in nonalcoholics
  • No evidence of relapse to drinking upon tobacco abstinence
alcohol dependence2
Alcohol Dependence
  • Higher rates of current smoking
  • In clinical settings, 85% to 90% are smokers
  • Many want to quit (up to 100% in one clinical study)
  • Quit rates in recovering groups same as nonalcoholics
  • Quit rates in active drinkers lower than in nonalcoholics
  • No evidence of relapse to drinking upon tobacco abstinence
what treatments work for alcohol dependent smokers
What treatments work for Alcohol Dependent smokers?
  • Bupropion (Zyban) same results as for nonalcoholic smokers
  • Nicotine replacement agents
  • Cognitive behavioral treatment for mood management helps alcoholic smokers with history of major depression
  • 12-step program enhanced effect of standard counseling treatment
how effective is smoking cessation treatment for smokers in recovery

How effective is smoking cessation treatment for smokers in recovery?

Over 25 studies to date

Most studies focused on either smokers in early recovery (< 3 months) or later recovery (> 1 year)

Treatment included behavioral counseling and medication (nicotine replacement, bupropion)

Rates of successful quitting

about 10% for smokers in early recovery

about 25% for smokers in later recovery

effect of trying to quit smoking on sobriety joseph et al 2003

Effect of Trying to Quit Smoking on Sobriety, Joseph et al, 2003

499 smokers in alcohol dependence treatment

Smoking treatment (counseling + NRT)

Concurrent or delayed (6 months)

Outcomes - smoking and drinking status

future research

Future Research

Factors affecting smoking cessation outcomes for alcoholics in early recovery

Saturated social network of smokers?

Combination pharmacotherapies (e.g., bupropion plus naltrexone)

More frequent smoking cessation counseling.

drug dependence
Drug Dependence
  • High rates of current smoking
    • 70% in cannabis dependent
    • 75% in cocaine dependent
    • 85%-98% in methadone-maintained
    • Extremely high levels of nicotine dependence
  • Claim that quitting smoking is hardest
  • Strong levels of interest in quitting
drug dependence1
Drug Dependence
  • High rates of current smoking
    • 70% in cannabis dependent
    • 75% in cocaine dependent
    • 85%-98% in methadone-maintained
    • Extremely high levels of nicotine dependence
  • Claim that quitting smoking is hardest
  • Strong levels of interest in quitting
drug dependence2
Drug Dependence
  • High rates of current smoking
    • 70% in cannabis dependent
    • 75% in cocaine dependent
    • 85%-98% in methadone-maintained
    • Extremely high levels of nicotine dependence
  • Claim that quitting smoking is hardest
  • Strong levels of interest in quitting
drug dependence3
Drug Dependence
  • High rates of current smoking
    • 70% in cannabis dependent
    • 75% in cocaine dependent
    • 85%-98% in methadone-maintained
    • Extremely high levels of nicotine dependence
  • Claim that quitting smoking is hardest
  • Strong levels of interest in quitting
slide44

Limited knowledge base on smoking cessation treatments for smokers with drug dependence.

  • Specially needed are studies that will clarify the bidirectional dynamic between tobacco dependence and drug dependence.
  • Review paper, Sullivan and Covey, Current Psychiatry Reports, 2002
methadone great place to start richter 2003
Methadone – Great Place to StartRichter, 2003
  • Medically oriented, not anti-pharmacotherapy
  • Patients get stable, can think long-term
  • Many patients are over 30 - many start having tobacco-related illnesses, so do friends
  • Patients stay in treatment for long periods, visit clinics regularly, develop relationships with staff
  • Methadone has consistent treatment guidelines and a strong national network (good for dissemination)
how to start
How to Start?
  • What are the best treatments?
  • When to treat?
  • What do patients want/have tried?
  • How to prevent relapse to other drugs?
  • What are providers doing now?
  • What do they find works best?
  • Etc.
percent service provided to at least 1 patient in the past 30 days
Percent service provided to at least 1 patient in the Past 30 Days

% Providing service to at least 1 patient

Zyban

NRT

Groups

Brief Advice

Counseling

Referral

Brochure

Acupunct.

most important barrier to providing smoking cessation services richter 2003
Staff not trained (118)

Patients not interested (111)

Other drug treatment more important (78)

Not enough staff (58)

Clinic does not receive reimbursement (49)

Staff are too busy (36)

Staff smoke cigarettes (20)

Smoking treatment is ineffective (7)

Other (33)

Most Important Barrier to Providing Smoking Cessation Services, Richter, 2003
lessons learned
Lessons Learned
  • There ARE barriers to offering services
    • #1 is lack of staff training
    • #2 is perception that patients aren’t interested
  • There are also BENEFITS to offering services
    • Improve health, outcomes, cleanliness
  • Few clinicians actively discourage/delay quitting
  • Perceptions that some patients appear to benefit from smoking (may explain why cessation treatment is not always offered?)
recommendations
Recommendations
  • Regulatory agencies could require/encourage clinics to in some way address nicotine addiction among stable patients
  • Methadone clinics need to offer Nicotine Dependence Treatment Training!
  • Find clinics that are already doing it, empower them to disseminate programs
  • Address benefits of tobacco use and alternate treatments for mood disorders
schizophrenia
Schizophrenia
  • High prevalence of smoking – 80-95%
  • Very low rates of complete abstinence
  • Smoking ameliorates symptoms
  • Smoking ameliorates medication side effects
  • Responsive and tolerant to NRT and bupropion
schizophrenia1
Schizophrenia
  • High prevalence of smoking – 80-95%
  • Very low rates of complete abstinence
  • Smoking ameliorates symptoms
  • Smoking ameliorates medication side effects
  • Responsive and tolerant to NRT and bupropion
schizophrenia2
Schizophrenia
  • High prevalence of smoking – 80-95%
  • Very low rates of complete abstinence
  • Smoking ameliorates negative symptoms
    • E.g., cognitive dysfunction
  • Smoking ameliorates medication side effects
  • Responsive and tolerant to NRT and bupropion
schizophrenia3
Schizophrenia
  • High prevalence of smoking – 80-95%
  • Very low rates of complete abstinence
  • Smoking ameliorates symptoms
  • Smoking ameliorates medication side effects
  • Responsive and tolerant to NRT and bupropion
schizophrenia4
Schizophrenia
  • High prevalence of smoking – 80-95%
  • Very low rates of complete abstinence
  • Smoking ameliorates symptoms
  • Smoking ameliorates medication side effects
  • Responsive and tolerant to NRT and bupropion
clinical trial ziedonis et al 1997
Clinical Trial (Ziedonis et al, 1997)
  • 24 Patients
  • Received NRT, behavioral counseling
  • Patients interested in participating
  • No worsening of psychiatric disorder
  • 50% completed 10 week program

13% abstinent for 24 weeks

clinical trial addington 1997
Clinical Trial, Addington, 1997,

50 Subjects, 7 weeks group counseling

10 weeks of NRT (patch)

- 42% abstinent at 7 weeks

- 16 % abstinent at 12 weeks

- 12% at 24 weeks

No change in symptoms of schizophrenia

No great difficulty in having schizophrenics use the patch

percent abstinent in clinical trial with nicotine patch and group counseling addington 1997
Percent abstinent in clinical Trial with Nicotine Patch and Group Counseling, Addington, 1997,

42%

16%

12%

bupropion and cbt evins et al
Bupropion and CBT, Evins et al,
  • 12 weeks Bupropion/placebo and weekly group counseling (n=19 subjects)
  • Abstinence verified by CO<9 ppm
  • Smoking reduction:

66% in bupropion vs. 11% in placebo

  • 1 patient on Bupropion quit smoking
  • No difference in positive symptoms
conclusions
Conclusions
  • It is possible for individuals with schizophrenia to stop smoking.
  • Nicotine replacement treatment and bupropion are helpful cessation aids for patients with schizophrenia.
slide61
Future directions: Overcoming traditional barriers to smoking cessation for smokers with mental illness
  • Presumption of low interest in quitting.
  • Fear that tobacco withdrawal may exacerbate current symptoms or provoke new episodes.
  • Need for evidence-based treatment approaches particularly for currently ill.
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