Patients with mental illness are more likely to be smokers than the general population — by far — and are much less likely to be able to quit. So, why should we care about this problem?
Many mental health professionals think, “If patients want to smoke cigarettes, so be it. They’ll only get annoyed with me if I bring it up, and besides, their symptoms will get worse if they try to quit, anyway.” There are many myths about smoking and mental illness, and many reasons why you should be the one to help your patients attempt to quit.
Most importantly, mortality for people with psychiatric illness from medical illnesses is markedly elevated. There are many reasons for this increased mortality, including obesity, metabolic disorders, and poor access to medical care. But by far the greatest risk for this is cigarette smoking.
While the general population continues to quit smoking (19% of American adults report being smokers), the rates for those with mental illness is not declining as fast. As a consequence, it appears that for some people with bipolar disorder and schizophrenia, death rates related to smoking are increasing compared to the general population. It’s not an accident that death rates are so high. People with mental illness smoke between 30% and 50% of all the cigarettes sold in the U.S. while comprising only about 7% of the population.
What have been the barriers to bringing smoking cessation into the mental health clinic? Some are due to provider attitudes. Patients don’t want to quit, smoking makes their symptoms better, and it’s their decision whether or not to quit. Some are from the lack of disseminated evidence about smoking cessation in mental illness, as most such studies enrolling subjects not also suffering from a psychiatric disorder.
Still others come from fears about evidence-based smoking cessation treatments. For example, some practitioners are wary of prescribing varenicline (Chantix) due to labeling that notes serious neuropsychiatric events associated with the drug.
Perhaps most significantly, clinicians may not feel that addressing smoking is within their scope of practice — or in their comfort zone. New data supports the use of pharmacotherapy for smoking cessation in mental illness as both safe and effective, and there are simple steps a clinician can take to become more familiar with engaging their patients in kicking the habit.
The effectiveness of smoking cessation therapies is strongest in schizophrenia. Bupropion hydrochloride (Zyban), a long-available medication for smoking cessation, is safe and effective.1 Another study found the benefits from combining standard behavioral therapy and varenicline in patients with schizophrenia and bipolar disorder. More than 40% of subjects in the open-label trial had 7-day point prevalence nicotine abstinence after 12 weeks of therapy, and about two-thirds of those had 7-day point prevalence nicotine abstinence after one year of maintenance therapy. There was no neuropsychiatric worsening noted.2
In a large trial in those who had suffered from depression in the past, varenicline was effective — and with improvement in mood symptoms, not worsening — in a cohort with moderate depression.3 A large cohort study also suggests that neither bupropion nor varenicline are associated with self-harm, giving further evidence to clinicians that using pharmacotherapy to assist in smoking cessation in people with mental illness is safe.4
Study data for smoking cessation in specific disorders has been difficult to come by, but integrating smoking cessation into mental health care, rather than referral to smoking cessation, appears to improve outcomes in some disorders, notably in post-traumatic stress disorder.5
The most tried and true way to engender behavioral change in patients is through motivational interviewing (MI). MI engages patient’s own ambivalence about their behavior to instill change. The principles of MI include empathy, developing discrepancy (reflecting back to patients how their behavior and values conflict), rolling with resistance (not knowing what is best for the patient), and developing self-efficacy (knowing that the patient is the agent of change).
Patients who smoke have drastically shortened life expectancies and are faced with a hands-off attitude with regards to smoking cessation treatment in many mental health settings. By implementing standard pharmacotherapy into practice and by engaging patients in behavioral change, we can move our patients towards becoming smoke-free, and have a great impact of the future health of those we treat.
Michael J. Ostacher, MD, MPH, is an Assistant Professor of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine. He is also Associate Director of the Bipolar and Depression Research Program at the Veterans Affairs Palo Alto Health Care System.
- Tsoi DT, et al. Cochrane Database Syst Rev. 2010; 16(6):CD007253.
- Evins EA, et al. JAMA. 2014; 311(2):145-54.
- Anthenelli RM, et al. Ann Intern Med. 2013; 159(6):390-400.
- Thomas KH, et al. BMJ. 2013; 347:f5704.
- McFall M, et al. JAMA. 2010; 304(22):2485-93.