Judith J. Prochaska, PhD, MPH

 During a routine return medication visit, your patient, a 45-year-old man with bipolar disorder, asks you about using an e-cigarette. You recall that he is a pack-a-day smoker, and when you last discussed his smoking about a year ago, he wanted to quit.

This clinical scenario is increasingly common for psychiatrists. Among people with mental illness, 15% have tried e-cigarettes compared with 7% of the general population, and use rates are on the rise.

 In a study comprising 956 cigarette smokers hospitalized for mental illness, trial use of e-cigarettes went from 0% in 2009 to 25% in 2013.

 In the general US population, among smokers, lifetime use of e-cigarettes increased from 10% in 2010 to 37% in 2013.

Given the disproportionate burden of tobacco health harms in psychiatric patients, e-cigarettes are being considered as a potential tool for harm reduction. This article summarizes recent data on e-cigarettes, provides recommendations and resources to learn more, and emphasizes the evidence for treating tobacco (traditional cigarettes) addiction in people with mental illness.

E-cigarettes (ie, vaporizers, vape pens, e-hookah) are battery-operated devices that generate an aerosol from an e-liquid for inhalation. Consisting of a metal tube resembling a traditional cigarette, a battery, an atomizer, and a replaceable cartridge, e-cigarettes usually contain liquid nicotine, propylene glycol (an irritant in antifreeze), glycerin, flavoring, and other chemicals. A user puffs on an e-cigarette, and the heating element aerates the cartridge solution. Many of these are intended to simulate a cigarette. Tank or open systems, discussed below, allow users to fill the device with any substance of choice.

Developed and commercialized in China in 2003, e-cigarettes entered the US market in 2006; however, tobacco companies such as Philip Morris have been researching precursors to e-cigarettes since 1990. Over the past decade, advertising and sales of e-cigarettes have increased exponentially every year, and the major tobacco retailers now dominate the market. While tobacco advertising has been banned from television and radio since 1970, e-cigarettes are promoted widely on these media channels, on the web, and in social media, with many ads reaching youth. In August 2016-10 years after entering the US market-e-cigarettes came under the regulatory authority of the FDA, but regulatory evaluations of the products are still in progress.

 Nicotine is a psychoactive drug that can be addictive. Nicotine delivery with e-cigarettes varies by device (greater with the tank systems than with the cigarette-like products) and by experience level of the user. As the technology improves, the speed and the amount of nicotine absorbed are likely to increase over time, along with addiction. Mislabeling has been found with nicotine present in products labeled as nicotine-free or at higher concentrations than labeled.

 Flavored options (eg, candy, alcohol, unicorn vomit) can appeal to youth, whose brains are vulnerable to early addiction exposure. E-cigarettes are widely available for purchase online, in convenience stores, and in neighborhood vape shops. Past-month e-cigarette use nearly tripled from 2013 to 2014 among high school students (4.5% to 13.4%), surpassing all other tobacco use.

 For the first time in decades, the percentage of US youth exposed to any nicotine product increased, from 2013 to 2014 and again from 2014 to 2015. Moreover, e-cigarettes may be a gateway to conventional smoking. Two studies of adolescents who were never-smokers at baseline found that e-cigarette use predicted greater risk of cigarette smoking at follow-up.

 Modifications to e-cigarettes (“mods”) and open tank systems allow users to vape other substances, most commonly cannabis oil. In an anonymous study of more than 7000 high school students, nearly 1 in 5 adolescents who use e-cigarettes reported using the device to vape cannabis oil.

. Nicotine in high doses, especially in children, can be dangerous and even fatal. Poison control calls for nicotine poisoning have increased from one call in September 2010 to 215 calls per month related to e-cigarette exposure in February 2014.

Combustible cigarettes kill two-thirds of long-term smokers.

 E-cigarettes do not involve combustion; therefore, if a smoker switches to e-cigarettes, carbon monoxide exposure and health harms will be reduced. Yet, the evidence regarding e-cigarettes as a cessation aid is limited; dual use with combustible cigarettes is common; and the safety of e-cigarettes has not been established.

Half of current smokers report regular use of e-cigarettes.

 Any use of cigarettes is harmful, and the concern is that individuals who use e-cigarettes will continue to smoke conventional cigarettes rather than quit. The strongest evidence in support of e-cigarettes for quitting smoking has come from observational studies in the UK. One study, a time-trend analysis, concluded that for every 1% increase in e-cigarette use, the success rate of quit attempts increased by 0.098%.

 In contrast, a second study in the UK found that daily use of e-cigarettes was associated with increases in quit attempts and reductions in number of cigarettes smoked, but not with smoking cessation.

Meta-analyses have been conducted to synthesize the findings in the literature. A systematic review of 20 controlled studies concluded that the odds of quitting cigarettes was 28% lower in those who used e-cigarettes than in those who did not use e-cigarettes.

 Observational designs are challenged by confounding variables related to who self-selects to use an e-cigarette. Only 2 randomized controlled trials have evaluated e-cigarettes as a method for quitting conventional cigarettes. The quality of evidence was judged to be low grade, and in both trials, e-cigarettes with nicotine were no different in efficacy for quitting smoking than placebo (nicotine-free) e-cigarettes.

 To date, research does not support the use of e-cigarettes for cessation.

The American Heart Association’s (AHA) policy statement on e-cigarettes does not recommend their use; however, if a patient has tried and failed evidence-based tobacco cessation methods or is unwilling to try them, the AHA recommends

• No dual use of traditional cigarettes with e-cigarettes

• That a quit date is also set for the e-cigarettes

Smokers with mental illness consume nearly half the cigarettes sold in the US and die on average 25 years earlier than the general population, largely from chronic diseases, most tobacco-related. Tobacco use also creates a significant economic burden on patients, increases isolation, and affects the metabolism of a number of psychiatric medications.

Despite the obvious need to treat tobacco addiction, there has been a historic reluctance to do so out of concerns that mental health functioning may worsen with cessation. In a 2007 AAMC (Association of American Medical Colleges) Survey of more than 3000 physicians, psychiatrists were the least likely to address tobacco addiction-although findings indicate that psychiatric outcomes improve with tobacco cessation.

 The tobacco industry also plays a role by promoting the self-medication hypothesis (ie, that cigarettes reduce psychiatric symptoms). However, cigarettes reduce withdrawal symptoms of nicotine rather than psychiatric symptoms. Symptoms of nicotine withdrawal can mimic psychiatric symptoms (depression, insomnia, irritability, anxiety, restlessness).

In contrast to the unknowns regarding e-cigarettes, there are evidence-based and well-established cessation treatments that are underutilized.

 There are 7 FDA-approved nicotine replacement therapies (NRTs) that significantly improve quit rates: 3 over-the-counter NRTs (patch, gum, lozenge); 2 prescription NRTs (spray, inhaler); and 2 oral pills (bupropion, varenicline). NRT reduces nicotine cravings and withdrawal without the reinforcing effects of smoked nicotine. It is important to educate the patient on the proper use of NRTs. For example, people use the gum like normal chewing gum, when in fact nicotine in the gum is best absorbed in the oral mucosa by parking the gum in the cheek.

Bupropion is well known in psychiatry and acts on dopamine, norepinephrine, and nicotinic-cholinergic receptors to decrease cravings and withdrawal symptoms. Varenicline is a partial agonist at the Î±4Î²2 neuronal nicotinic acetylcholine receptor; it relieves craving and withdrawal and reduces the reinforcing effects of nicotine by blocking dopaminergic stimulation. The best evidence is for varenicline and combination NRT (eg, a patch plus gum or lozenge). The choice of medication depends on history, patient input, cost, previous attempts, and severity of dependence/withdrawal and breakthrough symptoms.

 Cessation medications are most effective when combined with counseling. Integrating the Public Health Service guidelines of the 5 As-Ask, Advise, Assess, Assist, Arrange-into regular practice for treating smoking is an evidence-based approach. The AAR method is also effective and takes less than 5 minutes: Asking about smoking, Advising to quit, and Referring to a program.

The national toll-free quit line (1-800-QUIT-NOW) and the National Cancer Institute’s smokefree.gov website offer evidence-based resources. For patients who are not yet ready to quit smoking, empathy and a focus on the benefits of quitting (health, financial, social) are recommended to maintain rapport and raise motivation.

In the clinical scenario presented at the start, the psychiatrist had not inquired about tobacco use for a year. It is recommended that psychiatrists assess tobacco use at every visit. Since tobacco use can affect clinical presentation (withdrawal symptoms) and medication levels, asking about tobacco use is clinically indicated. Systems changes (eg, including tobacco use in a standard assessment, providing clinician prompts) can help integrate tobacco treatment within clinical practice. Furthermore, supporting a culture of health where facilities are smoke-free fosters the best outcomes for smoking cessation. Smoke breaks should not be promoted nor should clinicians engage in smoking with patients. Treating patients with empathy and encouraging the use of NRT can be extremely helpful.

The Sidebar highlights 3 evidence-based accessible clinician resources on e-cigarettes and tobacco cessation treatment. We encourage psychiatrists and other mental health care providers to continue to follow the growing fields of research and regulation on e-cigarettes and tobacco.

 Dr. Prochaska’s research is funded by the NCI (grant R01CA204356), the NHLBI (grant R01HL117736), and the TRDRP (grants 24RT-0035 and 25IR-0032).

This article was originally published on June 30, 2017 and has since been updated.

Dr. Das is Clinical Assistant Professor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine; Dr. Prochaska is Associate Professor of Medicine at the Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA.

Dr. Prochaska has been a consultant for Pfizer, which makes smoking cessation medications, and has been an expert witness for plaintiffs’ counsel in court cases against the tobacco companies.

 Cummins SE, Zhu SH, Tedeschi GJ, et al. Use of e-cigarettes by individuals with mental health conditions. 

 Prochaska JJ, Grana RA. E-cigarette use among smokers with serious mental illness. 

 King BA, Alam S, Promoff G, et al. Awareness and ever-use of electronic cigarettes among U.S. adults, 2010-2011. 

 Goniewicz ML, Gupta R, Lee YH, et al. Nicotine levels in electronic cigarette refill solutions: a comparative analysis of products from the U.S., Korea, and Poland. 

 Leventhal AM, Strong DR, Kirkpatrick MG, et al. Association of electronic cigarette use with initiation of combustible tobacco product smoking in early adolescence. 

 Miech R, Patrick ME, O’Malley PM, Johnston LD. E-cigarette use as a predictor of cigarette smoking: results from a 1-year follow-up of a national sample of 12th grade students. 

 Morean ME, Kong G, Camenga DR, et al. High school students’ use of electronic cigarettes to vaporize cannabis. 

 Rigotti NA. e-Cigarette use and subsequent tobacco use by adolescents: new evidence about a potential risk of e-cigarettes. 

 Chatham-Stephens K, Law R, Taylor E, et al. Exposure calls to US poison centers involving electronic cigarettes and conventional cigarettes: September 2010 to December 2014. 

 Pirie K, Peto R, Reeves GK, et al. The 21st century hazards of smoking and benefits of stopping: a prospective study of one million women in the UK. 

 Population Assessment of Tobacco and Health (PATH) Study Public-Use Files. Inter-University Consortium for Political and Social Research (ICPSR). 2017. 

 Beard E, West R, Michie S, Brown J. Association between electronic cigarette use and changes in quit attempts, success of quit attempts, use of smoking cessation pharmacotherapy, and use of stop smoking services in England: time series analysis of population trends. 

 Brose LS, Hitchman SC, Brown J, et al. Is the use of electronic cigarettes while smoking associated with smoking cessation attempts, cessation and reduced cigarette consumption? A survey with a 1-year follow-up. 

 Kalkhoran S, Glantz SA. E-cigarettes and smoking cessation in real-world and clinical settings: a systematic review and meta-analysis. 

 Hartmann-Boyce J, McRobbie H, Bullen C, et al. Electronic cigarettes for smoking cessation. 

 Bhatnagar A, Whitsel LP, Ribisl KM, et al. Electronic cigarettes: a policy statement from the American Heart Association. 

 American Association of Medical Colleges. Physician behavior and practice patterns related to smoking cessation, summary report. Washington, DC: Association of American Medical Colleges; 2007.

 Hall SM, Prochaska JJ. Treatment of smokers with co-occurring disorders: emphasis on integration in mental health and addiction treatment settings. 

Articles

This article summarizes data on e-cigarettes, provides recommendations and resources to learn more, and emphasizes the evidence for treating tobacco (traditional cigarettes) addiction in people with mental illness.

E-Cigarettes, Vaping, and Other Electronic Nicotine Products: Harm Reduction Pathways or New Avenues for Addiction?

This activity offers CE credits for:
1. Physicians (CME)
2. Other

To understand the obstacles standing in the way of smoking cessation in patients with mental illness and the strategies that can help patients abstain from smoking.

At the end of this CE activity, participants should be able to:

 Understand the obstacles that stand in the way of smoking cessation in patients with mental illness

 Describe the recommendations of the US public Health Service and the American Psychiatric Association to help patients quit smoking

 Describe the evidence base for treating tobacco addiction in smokers with co-occurring mental illness or addictive disorders

This continuing medical education activity is intended for psychiatrists, psychologists, primary care physicians, physician assistants, nurse practitioners, and other health care professionals who seek to improve their care for patients with mental health disorders.

CME Credit (Physicians): This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of CME Outfitters, LLC, and 

. CME Outfitters, LLC, is accredited by the ACCME to provide continuing medical education for physicians.

CME Outfitters designates this enduring material for a maximum of 

. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Note to Nurse Practitioners and Physician Assistants: AANPCP and AAPA accept certificates of participation for educational activities certified for 

It is the policy of CME Outfitters, LLC, to ensure independence, balance, objectivity, and scientific rigor and integrity in all of their CME/CE activities. Faculty must disclose to the participants any relationships with commercial companies whose products or devices may be mentioned in faculty presentations, or with the commercial supporter of this CME/CE activity. CME Outfitters, LLC, has evaluated, identified, and attempted to resolve any potential conflicts of interest through a rigorous content validation procedure, use of evidence-based data/research, and a multidisciplinary peer-review process.

The following information is for participant information only. It is not assumed that these relationships will have a negative impact on the presentations.

Stephen E. Hall, MD, has no disclosures to report.

Judith J. Prochaska, PhD, MPH, reports that she has received an independent investigator award from Pfizer and is an ad hoc member of their advisory board and grant reviewer for their grant program. She has also served as an expert witness against the tobacco companies in several lawsuits for which she has received fees.

A. Eden Evins, MD, MPH (peer/content reviewer), has no disclosures to report.

 staff and CME Outfitters staff have no disclosures to report.

Faculty of this CME/CE activity may include discussion of products or devices that are not currently labeled for use by the FDA. The faculty have been informed of their responsibility to disclose to the audience if they will be discussing off-label or investigational uses (any uses not approved by the FDA) of products or devices. CME Outfitters, LLC, and the faculty do not endorse the use of any product outside of the FDA-labeled indications. Medical professionals should not utilize the procedures, products, or diagnosis techniques discussed during this activity without evaluation of their patient for contraindications or dangers of use.

Tobacco smoking is the leading cause of preventable death in the US.

Despite a steady decline in smoking in the general population since 1965, its prevalence among adults with mental health and substance use disorders remains high, with recent estimates from 50% to 85%, which currently represents about 16 million people.

 This group consumes about half of all cigarettes sold in the US and suffers a disproportionate share of medical burden, including cardiovascular and pulmonary diseases as well as cancer associated with smoking.

 Half of all smokers alive today will be killed prematurely by a disease linked directly to their tobacco use.

This article addresses issues inherent in treating tobacco dependence in individuals with major mental illnesses and substance use disorders, including assessment approaches, treatment options, and potential risks.

Although some advances have been made in addressing the persistently high rate of smoking in the mentally ill, these are limited mainly to the research environment. A variety of factors that contribute to the lack of focus on this dangerous health risk have been suggested. These include:

• A perceived reluctance to address smoking in the clinical practice setting

• Historical use of cigarettes as contingency rewards in institutions

• The marketing of cigarettes to those with mental illness

• Inconsistent insurance coverage for tobacco use treatment

• Other psychiatric or substance abuse problems get priority

• The belief that smoking is a form of “self-medication” for some patients

• Clinicians’ fears that tobacco abstinence will cause decompensation of other conditions

• Lack of provider awareness, training, and education

Only half of US residency programs in psychiatry include training in the treatment of tobacco dependence.

 It is perceived that motivation to quit is low among smokers who have other substance abuse and mental health problems, but data suggest that this group is as interested in abstinence as is the general population.

Psychiatric inpatient hospitalization may be an especially fruitful time to mobilize interest in quitting and to initiate abstinence. In one recently published study of the efficacy of treatment for tobacco use on an inpatient service, measures of psychopathology did not predict abstinence, but measures of motivation and tobacco dependence did. Moreover, cessation treatment appeared to decrease the risk of rehospitalization, and the intervention was found to be highly cost-effective.

 Surveys of patients in substance abuse rehabilitation programs have found that the majority are motivated to quit, although a substantial number also express concern about their ability to quit tobacco and other substances simultaneously.

To overcome some of these obstacles, clinical and research leaders and policy advocates have proposed a systematic integration of tobacco dependence treatments into mental health programs.

 A successful example using this model is a large study from the Veterans Administration, which demonstrated that patients with PTSD and tobacco dependence who were treated for both disorders simultaneously had 2-fold greater quit rates than those who received care through referral to a smoking cessation clinic.

 Moreover, smoking cessation had no adverse effects on PTSD recovery. Because smoking so commonly co-occurs with mental illness, integrated psychiatric/ tobacco dependence treatment may be more cost-effective than the traditional split. In the approaching era of population-based systems of care, economic and clinical imperatives may hasten the adoption of such a model.

The US Public Health Service update of 2008 provides an excellent guide to the assessment and treatment of tobacco use and dependence.

 These guidelines are for smokers in general, but serve as the basis for recommended approaches for smokers with comorbid psychiatric or substance use disorders. The individualized approach includes:

• Advice to quit in clear and personalized terms

• Understanding specific health concerns

• Assessment of the individual’s willingness to quit

Clinicians can help patients move toward smoking cessation with motivational interviewing. This technique addresses specific content areas (relevance, risks, rewards, roadblocks, and repetition) and is associated with improved quit attempts.

Treatment options include referral to smoking cessation programs or the national telephone “quit line” (1-800-QUIT-NOW), practical counseling (eg, problem-solving/skills training), and medication support. Medications include nicotine replacement therapy (approved by the FDA in the form of patch, gum, lozenge, nasal spray, and inhaler), antidepressants (bupro- pion SR and nortriptyline), and an Î±4Ã2 nicotinic receptor partial agonist (varenicline).

Monotherapy with varenicline has been shown to be more effective than other monotherapies and comparable to the combination of multiple forms of nicotine replacement (eg, patch plus gum or lozenge).

 In addition, the combination of nicotine replacement and bupropion SR has shown greater efficacy than either used alone.

 Case reports and postmarketing data raised concerns about the risk of psychiatric adverse effects from both varenicline and bupropion SR, and in 2009, boxed warnings were added to labeling for both medications.

 Clinical trials data have not indicated a signal of concern, including in recent trials of varenicline use among smokers with current mental illness.

In its practice guidelines for nicotine dependence and substance use disorders, the American Psychiatric Association recommends assessment of smoking status in all patients and assistance with quitting.

 The guidelines recommend use of motivational, behavioral, and pharmacological treatment; suggest using inpatient treatment as a good opportunity for initiating abstinence; and recommend nicotine replacement therapy for withdrawal symptoms. The guidelines note that with few exceptions, there is limited evidence for treatment interventions specific for smokers with particular psychiatric diagnoses.

Depression is twice as common in smokers as in nonsmokers, and 4 times as common in heavy smokers.

 Smokers with comorbid depression smoke more heavily than the average smoker, are more likely to relapse after an attempt to quit, and suffer greater physical morbidity and mortality than those in the general population.

 Prospective studies with adolescents and adults have implicated tobacco use as a predictor of future suicidal behavior.

 But some have expressed concern that past or currently depressed patients who quit smoking will lose a coping mechanism and decompensate.

Among patients with a history of depression, there are limited, discrepant data regarding the risk of smoking cessation. Findings from one prospective trial of sertraline for smoking cessation suggest that quitters had a higher rate of depressive relapse.

 However, a large percentage of continuing smokers were lost at follow-up, potentially underreporting depression recurrence in that group (sertraline itself was ineffective for abstinence).

In secondary analyses of 2 clinical tobacco treatment trials in smokers with a history of depression, smoking cessation did not increase rates of depressive symptoms or of major depressive relapses.

 Furthermore, in one of the only trials to test a cessation intervention among currently depressed smokers, quitting smoking, measured over 18 months, did not harm recovery from depression.

Nicotine withdrawal can produce some depressive symptoms for a 2- to 4-week period irrespective of depression history. Long-term effects, however, are encouraging: a recent meta-analysis found that smoking cessation is associated with reduced depression, anxiety, and stress and improved positive mood and quality of life compared with continuing to smoke, true for smokers with and without a history of depression.

Medications that are effective for tobacco cessation in smokers without mental illness have also shown similar effectiveness in patients with either current or prior depression. Bupropion SR does not have a differential effect on patients with a history of depression, as had once been hoped.

Varenicline more than doubled the odds of sustained tobacco abstinence compared with placebo for patients under stable treatment for current or past major depression, without exacerbating anxiety or depressive symptoms.

 In an analysis of data from the VA health care system that compared varenicline with nicotine replacement therapy, no differences in rates of neuropsychiatric hospitalization were observed; findings were similar in the subsets of patients with and without a neuropsychiatric history who received either varenicline or a nicotine patch.

Rates of smoking in patients with schizophrenia are among the highest of any group. Combined with comorbid obesity and other metabolic disorders so common in this population, the results can be particularly deadly. Persons with serious mental illness die on average 25 years prematurely.

Only in recent years has there been an effort to address tobacco dependence in those with schizophrenic spectrum illnesses. Quit rates have been low, particularly with nicotine replacement therapy as the sole medication adjunct to psychological approaches.

 However, the combination of nicotine replacement therapy and behavioral counseling has been found to be effective (20% quit rate) in smokers hospitalized with schizophrenia, which was comparable to other diagnostic patient groups.

Concerns among clinicians that smoking cessation will exacerbate symptoms are not borne out by available data. In a trial that examined the use of bupropion for smoking cessation in schizophrenia, abstinence was not associated with worsened cognitive deficits or executive functioning.

 The combination of nicotine replacement therapy and bupropion was found more effective in 2 trials, with quit rates as high as 50% at the end of 12 weeks.

 However, relapse rates in both studies were high. Notably, there were no signals that abstinence or an attempt to quit worsened psychiatric symptoms.

More recently, varenicline was evaluated in a multicenter, randomized, controlled trial.

 Quit rates were 19% at 12 weeks and 11.9% at 24 weeks, with an odds ratio of about 5.0 relative to placebo. Varenicline was not associated with an exacerbation of schizophrenic symptoms or with changes in mood and anxiety ratings.

In a randomized placebo-controlled trial, extended use of varenicline (for 52 weeks) with CBT was found to prevent relapse among smokers with schizophrenia or bipolar disorder.

 From weeks 12 through 76, 30% of participants randomized to varenicline compared with 11% in the placebo group were continuously abstinent, with an odds ratio of 3.4. The CBT interventions focused on relapse prevention skills, such as understanding relapse, learning and applying skills, refusal skills, and problem solving.

A combination of social, psychological, and biological factors may lie behind the refractory nature of smoking among persons with schizophrenia. This population may be less aware of the associated health risks and feel that smoking is more important for their social functioning and acceptance. If noted during an evaluation, these factors could potentially be addressed in a personalized treatment plan.

 In general, heavy smokers have more difficulty in quitting, and persons with schizophrenia are generally heavy smokers.

Schizophrenia is characterized by deficits in executive planning as well as by resistance to change, so that even a motivated person may repeatedly lose focus on the goal of quitting cigarettes. Tobacco smoke (not nicotine) induces the metabolism of several antipsychotic medications (eg, olanzapine, haloperidol), which lowers blood levels and may reduce neurocognitive medication adverse effects. Nicotine also may have a facilitative role in cognitive processes that are impaired in schizophrenia.3 Thus, it may make sense to include nicotine replacement therapy in the smoking cessation plan for any patient with schizophrenia and to consider varenicline ahead of other medication options.

Traditionally, tobacco has not been included with other abused substances by rehabilitation programs as a target for abstinence. Perhaps because of its previously wide social acceptance and long-standing legal status, it has been relegated to a second-tier concern. However, evidence indicates that for some substance use disorders, continued smoking is associated with lower levels of sobriety from illicit drugs and alcohol.

A 2004 meta-analysis of 19 randomized controlled trials that evaluated tobacco cessation interventions with smokers in treatment or recovery for alcohol or illicit drug problems found significant posttreatment effects for quitting smoking, and nicotine replacement therapy was particularly helpful. Although tobacco cessation treatment effects were not maintained at long-term follow-up, notably there was a 25% improvement in long-term sobriety among those randomized to receive interventions for quitting smoking.

A large-scale study of treatment for alcohol dependence with tobacco cessation treatment administered either concurrently or with a 6-month delay, suggests that the timing of the two treatments may be important.

 At 18 months, subjects in the concurrent group were more likely than those in the delayed group to participate in smoking interventions, although at 18 months, abstinence rates in the two groups were similar. Alcohol abstinence rates were worse in the concurrent group at month 6, although not at months 12 and 18. Further research is needed to identify of the optimal timing of tobacco cessation interventions within addiction treatment settings, which may differ depending on the approach taken (eg, action-oriented “quit now” versus matched to stage of change or motivation).

Other major mental illnesses have received relatively little attention with regard to the treatment of comorbid tobacco dependence. Although adults with bipolar disorder are 2 to 3 times more likely to smoke, and less likely to stop than those without psychiatric disorders, this area has received little attention. In patients with anxiety disorders, there is a high prevalence of co-occurring tobacco dependence, but few studies have addressed treatment beyond the study of integrated tobacco cessation for smokers in treatment for PTSD in the VA health care system.

Treating tobacco dependence in smokers with mental health concerns is recommended as good clinical practice, is straightforward, and has demonstrated efficacy, without harm to mental health recovery. It is time to address the major health disparities related to tobacco use in this vulnerable population by providing evidence-based cessation treatment and referrals.

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Dr Hall is Clinical Professor of Psychiatry at the University of California, San Francisco; when this article was written, he was Director of Intensive Services at the Langley Porter Psychiatric Institute. He is currently Associate Director for Development in the department of psychiatry at The Jewish Home of San Francisco. Dr Prochaska is Associate Professor of Medicine with the Stanford Prevention Research Center in the department of medicine at Stanford University, Stanford, Calif.

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 Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness: a population-based prevalence study. 

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 Grant BF, Hasin DS, Chou SP, et al. Nicotine dependence and psychiatric disorders in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. 

 Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff. A clinical practice guideline for treating tobacco use and dependence: 2008 update: A US Public Health Service report. 

 Prochaska JJ, Fromont SC, Louie AK, et al. Training in tobacco treatments in psychiatry: a national survey of psychiatry residency training directors. 

 Prochaska JJ, Hall SE, Delucchi K, Hall SM. Efficacy of initiating tobacco dependence treatment in inpatient psychiatry: a randomized controlled trial. 

 Barnett PG, Wong W, Jeffers A, et al. Cost-effectiveness of smoking cessation treatment initiated during psychiatric hospitalization. 

 Williams JM, Steinberg ML, Griffiths KG, Cooperman N. Smokers with behavioral health comorbidity should be designated a tobacco use disparity group. 

 McFall M, Saxon AJ, Malte CA, et al; CSP 519 Study Team. Integrating tobacco cessation into mental health care for posttraumatic stress disorder: a randomized controlled trial. 

Motivational Interviewing: Preparing People for Change

. 2nd ed. New York: Guilford Press; 2002.

 Carpenter MJ, Hughes JR, Solomon LJ, Callas PW. Both smoking reduction with nicotine replacement therapy and motivational advice increase future cessation among smokers unmotivated to quit. 

 Cahill K, Stevens S, Perera R, Lancaster T. Pharmacological interventions for smoking cessation: an overview and network meta-analysis. 

. May 31, 2013. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009329.pub2/pdf. Accessed January 29, 2015.

 Gibbons RD, Mann JJ. Varenicline, smoking cessation, and neuropsychiatric adverse events. 

 Practice guidelines for the treatment of patients with nicotine dependence. American Psychiatric Association. 

Here: assessment approaches, treatment options, and potential risks inherent in treating tobacco dependence in individuals with major mental illnesses and substance use disorders.

Judith J. Prochaska, PhD, MPH

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