Smoking and Behavioral Health Steven A. Schroeder, MD University of California, San Francisco June 22, 2004
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.
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. • 37% of psychiatric hospitals still allow smoking inside their facilities.
Background cont. (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.
Background cont. (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.
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.
Anxiety disorders and tobacco • The presence of an anxiety disorder with or without concurrent depression is associated with an increased likelihood of smoking.
Smoking and anxiety • 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.
Smoking and alcohol dependence • Smokers have a 2-3 times greater risk for alcohol dependence than nonsmokers. • An estimated 80% of alcoholics currently smoke.
Alcohol cont. • More alcoholics die from smoking-related diseases than from alcohol- related ones. • Both founders of Alcoholics Anonymous died from their tobacco addictions.
Smoking and 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.
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%.
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.
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.
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.”
Reasons for Not Helping Patients Quit 1. Too busy 2. Lack of expertise 3. No financial incentive 4. Most smokers can’t/won’t quit 5. Stigmatizing smokers 6. Respect for privacy 7. Negative message might scare away patients 8. I smoke myself
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.
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.
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.
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.
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.
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.
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.
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.
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 can’t quit.
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.
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.
Question of Causality cont. (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.
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.
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.
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.
Secondhand Smoke cont.(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.
What Can Be Done? • Mental health field needs to embrace smoking cessation. • Clinicians are in an excellent position to intervene. • Intervention need not be onerous. • Those with outpatient conditions can often be referred to quitlines.
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.
What About Those Who Can’t 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