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What does the new set of U.S. Public Health Service guidelines for treating tobacco dependence say? Should everyone, regardless of mental health status, receive treatment?
Tobacco use has been cited as the chief avoidable cause of illness and death in our society, responsible for more than 430,000 deaths in the United States each year (Centers for Disease Control and Prevention, 1999). Smoking is a known cause of cancer, heart disease, stroke, complications of pregnancy and chronic obstructive pulmonary disease (U.S. Department of Health and Human Services, 1990). The enormous public health implications associated with tobacco use were the impetus for last year's U.S. Public Health Service (PHS) guideline Treating Tobacco Use and Dependence (Fiore et al., 2000). The guideline identified a number of effective treatments for tobacco dependence and recommended that all smokers, including those with psychiatric comorbidities, be offered appropriate treatment.
Smoking rates are substantially higher among individuals with a lifetime history of mental illness (35%) than among individuals without such a history (22.5%) (Lasser et al., 2000). This naturally raises the questions of whether and how to intervene with such individuals.
The PHS guideline (Fiore et al., 2000) strongly encouraged tobacco cessation intervention in individuals with psychiatric comorbidities. Tobacco dependence is extremely common among comorbid psychiatric populations (smoking rates can exceed 70% in alcohol and other substance abuse populations) (Fiore et al., 2000), and studies show that smoking-cessation treatments can be effective with such patients (Bobo et al., 1998; Ziedonis and George, 1997). Moreover, preliminary studies have shown that smoking-cessation treatment exacerbates the underlying comorbid psychiatric conditions. Thus, while clinicians should exercise due caution, they should still treat patients for tobacco dependence.
In this article, we will look beyond guideline recommendations to explore issues encountered in delivering tobacco dependence treatments to three separate comorbid populations: smokers with depression, schizophrenia and non-tobacco substance abuse problems. We will then examine guideline treatment recommendations and illustrate how they are relevant to comorbid populations. Treatments that are efficacious for smokers in general are also efficacious for smokers with a psychiatric comorbidity.
Depression is more common among smokers than non-smokers (60% versus 15%) (Borrelli et al., 1996). In addition, as many as 30% of patients seeking smoking-cessation treatment may have a history of depression (Anda et al., 1990, as cited in Fiore et al., 2000). Glassman et al. (1988) found that subjects without a history of depression are more than twice as likely to quit smoking than those with a history of depression.
While studies show that treating tobacco dependence in patients with comorbid conditions results in little adverse effect, the exception is patients with a history of depression, for whom smoking cessation may elicit or exacerbate depression (Fiore et al., 2000). For example, patients with a history of depression are more likely to experience depressive episodes after being treated for tobacco dependence than are smokers without such a history (Covey et al., 1998; Tsoh et al., 2000).
Patients with schizophrenia have a high rate of nicotine dependence (up to 88%) compared to the average population (about 25%) (George et al., 2000), yet few cessation programs target these smokers. This population has a particularly high risk for smoking-related death and disease because of their typically low motivation to quit smoking and their high levels of dependence (George et al., 2000). In addition, smoking cessation may affect the pharmacokinetics of certain psychiatric medications (George et al., 2000; Hughes, 1993).
New studies have shown that it is possible to treat patients with schizophrenia for their tobacco dependence. A study by George et al. (2000) indicated that patients who were treated with atypical antipsychotic medications (clozapine [Clozaril], risperidone [Risperdal], olanzapine [Zyprexa], quetiapine [Seroquel]) versus typical antipsychotic medications (perphenazine [Etrafon], fluphenazine [Prolixin], haloperidol [Haldol], chlorpromazine [Thorazine], thiothixene [Navane]) along with the transdermal nicotine patch reported higher quit rates. One possible reason for this high quit rate is that atypical antipsychotics may mimic nicotine's effects on the central nervous system, thus minimizing withdrawal symptoms (Ziedonis and George, 1997).
A 1997 report by Ziedonis and George on nicotine use and schizophrenia indicated that smoking-cessation treatments can be effective for psychiatric patients, but it decried the dearth of literature focusing on schizophrenia. They suggested that more extensive clinical research is needed to better define both the mechanisms of nicotine on the central nervous system of patients and the basic pathophysiological processes involved in schizophrenia.
Among substance abusers, smoking rates are well above the population average (Budney et al., 1993; Clemmey et al., 1997; DiFranza and Guerrera, 1990). Rates of alcoholics who smoke exceed 70%; they are more likely to be highly nicotine dependent than patients without such a comorbid condition (Bobo et al., 1998, as cited in Fiore et al., 2000).
Clinicians have been reluctant to encourage recovering alcoholics to try to quit smoking because of fears that smoking cessation may keep patients from completing their treatment for alcoholism, or that the stress of nicotine withdrawal will cause patients to relapse to drinking (Bobo et al., 1998). A study by Campbell et al. (1995), however, indicated that treatment can be provided without necessarily leading to relapse with other substances.
Studies have shown that concurrent treatment of non-tobacco substance abuse and tobacco dependence can be successful and that patient awareness of the benefits of treating both addictions can increase abstinence rates. In one study (Bobo et al., 1998), patients who were encouraged to quit smoking remained abstinent from alcohol at a rate that was twice as high as rates achieved by patients not encouraged to quit smoking. Unfortunately, studies also illustrate that smokers with past or current alcohol problems have a more difficult time remaining abstinent from tobacco than do smokers without such a history (Hays et al., 1999).
Smokers should be provided with practical counseling, support and pharmacotherapy, which, if delivered appropriately, can also effectively treat individuals with psychiatric comorbidities.
For example, the guideline found that buproprion Sustained Release (Zyban) (as a first-line agent) and nortriptyline (Aventyl, Pamelor) (as a second-line agent) are efficacious treatments for tobacco dependence. These drugs have also been approved for the treatment of depressive disorders. (The brand name Wellbutrin is used for buproprion for depression.) As a result, the guideline recommended that clinicians especially consider the use of these pharmacotherapeutic agents in smokers with a current or previous depression (Fiore et al., 2000).
The guideline also recommended that, where possible, smokers receive intensive counseling interventions, which are more effective than brief counseling. This is also consistent with evidence that intensive interventions produce higher abstinence rates in patients with psychiatric comorbidities than do less intensive interventions.
Specifically, a 1994 study by Hall et al. on the efficacy of a more intensive cognitive-behavioral intervention and nicotine gum versus a less intensive standard treatment (group support and nicotine gum) indicated that subjects with a history of major depressive disorder had higher quit rates when they received the more intensive intervention. Additionally, a study comparing the efficacy of counseling strategies with patients having low versus high levels of negative affect indicated that subjects displaying high negative affect were more likely to benefit from support counseling as opposed to skill training (Zelman et al., 1992). Intensive counseling sessions have also been reported to increase quit rates in patients with alcoholism (Bobo et al., 1998).
The guideline also discussed how the implementation of these strategies should not raise undue concern. Studies show that psychiatric inpatients are able to quit smoking without an increase in aggression (Smith et al., 1999). Moreover, evidence indicates that smoking-cessation interventions do not interfere with recovery from chemical dependency. Therefore, smokers receiving treatment for chemical dependency should also be provided smoking-cessation treatments, including both counseling and pharmacotherapy (Burling et al., 1997).
The guideline does note that clinicians need to exercise caution in treating patients with psychiatric comorbidities (Fiore et al., 2000). Mental health care professionals should carefully monitor a patient's progress during a quit attempt and be prepared to intervene if necessary.
Although the studies discussed here strengthen the case for treating tobacco dependence in patients with psychiatric comorbidities, additional research is needed; the guideline highlighted several areas for future research (Fiore et al., 2000). Clinical culture and practice patterns need to change in order to ensure that all patients who use tobacco, including those with psychiatric comorbidities, are identified and offered treatment. While smokers with comorbid conditions have a greater risk of relapse, there is no evidence that patients relapse to their previous psychiatric condition while making a quit attempt. In fact, most evidence suggests that abstinence results in little adverse impact. Given the harmful nature of continued tobacco use and the existence of effective treatments, the guideline recommended treating smokers with comorbid psychiatric conditions with the same treatments identified as being efficacious for the general population (Fiore et al., 2000).
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