Smoking rates among those suffering from mental illness or substance
abuse are two to four times higher than in the general population, ranging
from 50-90%.1 These individuals consume 44% of the cigarettes smoked in
the United States.2 People with mental illness not only have higher rates
of smoking but they smoke more cigarettes per day and take in more
nicotine per cigarette, leading to higher levels of dependence.3 Tobacco
use is a significant cause of morbidity and mortality in this population.
People with serious mental illness die on average 25 years younger than
the general population, with the cause of death often linked to smoking.4
Most published research focuses on the prevalence, predictors, and
negative consequences of smoking in persons with bipolar disorder rather
than effective cessation treatment. National data suggest that, among
those who suffer from bipolar disorder, 61% are current smokers.2 Smoking
is associated with more severe forms of bipolar disorder, concurrent
alcohol and drug use, and co-morbid psychiatric disorders.5
In general, the literature suggests that smoking cessation, when
undertaken with appropriate support, does not exacerbate mental illness.
In some cases, quitters experience lower levels of affective distress than
those who continue to smoke.6 According to clinical practice guidelines,
the most effective treatment for nicotine dependence includes both
medication and counseling.7 Among all smokers, the combination of a long-
acting nicotine replacement therapy (NRT) patch (to provide steady state
nicotine levels) and short-acting NRT gum or nasal spray (to treat
breakthrough cravings) is associated with the highest abstinence rates.7
Research on schizophrenia suggests that people with mental illness require
a more flexible and gradual approach to quitting and that nicotine
replacement therapy may be especially beneficial for this population.8-10
Because they smoke more, individuals with mental illness may require
higher doses of cessation medication for longer periods of time.8 In
addition, smoking increases the metabolism of many psychiatric drugs;
smokers may need up to twice as much medication as non-smokers and may
require dose adjustments when quitting.3
In Ms. G’s own words, the statement, “I am committed to stopping
smoking” is immediately followed by, “I guess I’m not full-hearted into
quitting.” I would begin by exploring this ambivalence in more detail.
What does she like about smoking? What good things might happen if she
quits? What do those four cigarettes represent for her? After assessing
her goals and current readiness to change, I would discuss the possibility
of discontinuing Chantix in favor of NRT - using the patch to maintain
baseline levels of nicotine in combination with the lozenge to replace the
remaining four cigarettes. Ms. G’s past experience indicates that
continued participation in regular individual and group support would also
be beneficial.
Ms. G. may need medication and support for an extended period of
time. An effective treatment plan will take into account the fact that
periods of unstable mood in the future will place her at risk for relapse.
I would encourage her to view quitting as a process and congratulate her
on her progress so far.
No relevant financial interests.
1. Williams JM, Ziedonis D. Addressing tobacco among individuals with
a mental illness or an addiction. Addictive Behaviors. 2004;29(6):1067-83.
2. Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental
illness: A population-based prevalence study. JAMA. 284(20):2606-10.
3. Ziedonis D, Williams JM, Smelson D. Serious mental illness and
tobacco addiction: a model program to address this common but neglected
issue. Am. J. Med. Sci. 2003;326(4):223-30.
4. National Association of State Mental Health Program Directors.
Morbidity and Mortality in People with Serious Mental Illness. Thirteenth
in a Series of Technical Reports.. Alexandria, Virginia; 2006.
5. Waxmonsky JA, Thomas MR, Miklowitz DJ, et al. Prevalence and
correlates of tobacco use in bipolar disorder: data from the first 2000
participants in the Systematic Treatment Enhancement Program. Gen Hosp
Psychiatry. 27(5):321-8.
6. Currie S, Karltyn J, Lussier D, et al. Outcome from a Community-
based Smoking Cessation Program for Persons with Serious Mental Illness.
Community Mental Health Journal. 2008;44(3):187-194.
7. Fiore M, Jaen C, Baker T. Treating Tobacco Use and Dependence.
2008 Update. . Rockville, MD: U.S. Department of Health and Human
Services. Public Health Service; 2008.
8. Williams JM, Ziedonis DM, Foulds J. A case series of nicotine
nasal spray in the treatment of tobacco dependence among patients with
schizophrenia. Psychiatric Services (Washington, D.C.). 2004;55(9):1064-6.
9. Williams JM, Foulds J. Successful Tobacco Dependence Treatment in
Schizophrenia. Am J Psychiatry. 2007;164(2):222-227.
10. McChargue DE, Gulliver SB, Hitsman B. Would smokers with
schizophrenia benefit from a more flexible approach to smoking treatment?
Addiction. 2002;97(7):785-93; discussion 795-800.
Readers Responses: ![[Read Readers Response]](/icons/misc/sectionDOWN.gif){kind=icon}
