Psychiatrists Should Be Armed in War Against Smoking

People with mental illness lose decades of their lifespan compared with the general public, and cigarette smoking contributes substantially to this glaring disparity. Now, a wealth of tools and resources is at psychiatrists' fingertips to help them integrate smoking-cessation treatment into their daily practice.

Although tobacco use has been declining for several decades in the general public, the proportion of smokers remains high among those with psychiatric disorders. Research has shown that 75 percent to 85 percent of patients with serious mental illnesses, such as schizophrenia and bipolar disorder, use tobacco and that 44 percent of cigarettes sold in the United States are consumed by people with a mental illness.

“It is time for psychiatrists to integrate smoking cessation [interventions] into their practice,” said Douglas Ziedonis, M.D., M.P.H., in an interview with Psychiatric News. “In the past 10 years, we have learned a lot more about the medical outcomes of [psychiatric] patients.”

Ziedonis is chair of the Department of Psychiatry at the University of Massachusetts (UMass) Medical School and UMass Memorial Medical Center and an expert in tobacco dependence.

He pointed out that mentally ill patients are particularly vulnerable to cancers and cardiovascular diseases, not only because so many of them smoke, but also because the symptoms of their illnesses and the metabolic side effects of many pharmacotherapies compound the health risks that smoking aggravates.

A CDC analysis of 1997-2000 data from eight states showed that the relative risk of death for public mental health clients was higher than for state general populations. Deaths among public mental health clients ranged from 1.2 to 4.9 times higher than the expected number of deaths in those states. Using nationwide life-expectancy data, the study found that the average number of potential years of life lost by a deceased mental health client ranged from 14 years to 32 years in the eight states. The leading causes of death included heart disease, cancer, and cerebrovascular, respiratory, and lung diseases.

“Psychiatrists can do a lot in their practice,” said Ziedonis.“ They know how to assess patients' motivation [to quit smoking] and how to motivate them.” Psychiatrists can integrate smoking cessation seamlessly into their routine screening and, if necessary, can do so with behavioral interventions for alcohol and substance use problems as well, he suggested.

Steven Schroeder, M.D., founder and director of the Smoking Cessation Leadership Center based at the University of San Francisco (UCSF), agreed.“ Psychiatrists can become experts themselves,” he told Psychiatric News.

Alternatively, psychiatrists can encourage and refer patients to treatment programs provided by health care systems such as Kaiser Permanente and the Mayo Clinic or to free smoking-cessation hotlines such as (800) QUIT-NOW, Schroeder suggested.

Both the UMass Medical Center and UCSF have incorporated tobacco-addiction treatment into psychiatric residency training, according to Ziedonis and Schroeder. For practicing psychiatrists, a vast number of resources are available online that can help them become experts in helping patients quit smoking (see Original article: Smoking-Cessation Resources for Health Professionals).

One of these online resources is “Bringing Everyone Along,” a project funded by the American Legacy Foundation, a nonprofit organization created from the tobacco-industry legal settlement in 1999. Among the manuals, toolkits, resource guides, and pamphlets, the Web site offers an online continuing medical education module for physicians on treating tobacco addiction.

The Smoking Cessation Leadership Center's Web site also contains resources and educational materials, including training videos and Webcasts for health care professionals interested in learning to conduct tobacco screening and interventions. In January the center published a toolkit designed specifically for mental health providers titled “Smoking Cessation for Persons With Mental Illnesses.”

Interventions Succeed

It is largely a myth that psychiatric patients are resistant to smoking cessation, said Ziedonis. The majority of smokers, including those with mental illness, do want to quit, but are often unsuccessful without professional intervention, according to Ziedonis and Schroeder.

Rather than expecting patients to quit on their own, physicians may find more success in helping patients stop smoking by combining behavioral interventions and medications. For example, Ziedonis noted, psychiatrists can integrate smoking cessation into their discussions with patients about self-destructive behaviors and help them implement behavioral changes, such as using a smoking log, that can lead patients to understand craving triggers and manage slips and relapses.

Two of the medications used to promote smoking cessation, bupropion and varenicline, are now subject to a boxed warning for increased risk of suicidal thoughts and behaviors. However, Ziedonis believes that concerns about varenicline should not prevent psychiatrists from prescribing it for patients who want to try the treatment, as long as they are carefully monitored. Also,“ psychiatrists are very comfortable with prescribing and monitoring bupropion,” he said. In addition, five types of FDA-approved nicotine-replacement treatments can work for many patients. These include nicotine gums, transdermal patches, lozenges, nasal sprays, and inhalers.

“Nicotine replacement is far safer than smoking,” said Ziedonis.

More Changes Are Coming

On June 22 the Food and Drug Administration (FDA) gained the right to regulate tobacco products after President Obama signed the Family Smoking Prevention and Tobacco Control Act into law. The agency has established a Center for Tobacco Products and is seeking public comments related to the writing of regulatory guidelines.

As mandated by the new law, tobacco manufacturers and importers will begin to report to the FDA the ingredients in their products by January 2010. Later in 2010, the companies will need FDA approval to use the terms“ light,” “low,” or “mild” on their products. By October, warning labels for cigarettes will be strengthened.

Both Ziedonis and Schroeder urged psychiatrists to do more to help patients stop smoking.

Smoking cessation is a “health-disparity issue, a stigma issue” for mentally ill individuals, Ziedonis believes. He argues that it is long overdue for patients with mental illness to receive aggressive smoking interventions.

“If you want to help your patients get healthy, you need to take smoking as seriously as mental illnesses, because it is the most likely cause to kill your patients,” Schroeder said.

The CDC study is posted at<www.cdc.gov/pcd/issues/2006/apr/05_0180.htm>. The Smoking Cessation Leadership Center's toolkit is posted at<http://smokingcessationleadership.ucsf.edu/Downloads/catolgue/MHtoolkitJan_2009.pdf>.▪