The prevalence of Americans who smoke is at a historic low—20
percent, probably the lowest since the 1920s.
So reported Steven Schroeder, M.D., director of the Smoking Cessation
Leadership Center of the University of California, San Francisco, at a recent
teleconference. The teleconference was sponsored by the Journal of the
American Medical Association (JAMA) and the Institute for Healthcare
Improvement. Some 75 psychiatrists and mental health professionals joined
But the news regarding smoking prevalence among Americans with mental
illness is much less heartening, Schroeder pointed out. Although persons with
mental disorders, including substance use disorders, constitute about a fifth
of the American population, they consume 44 percent of all the cigarettes
bought and smoked. And generally the more severe the psychiatric condition,
the higher the rate of smoking; some 80 percent of persons with schizophrenia
Data Counter 'Common Wisdom' of Smoking and Schizophrenia).
Moreover, "a recent study showed that on average persons with [chronic,
severe] mental illness die about 25 years earlier than the rest of the
population, and a huge chunk of that is from smoking," Schroeder
So is anything being done to help the latter quit smoking? Yes, Schroeder
said. Three years ago, 41 percent of psychiatric hospitals were smoke free;
now it is 49 percent. Further good news is that requiring inpatients to give
up smoking has not exacerbated their mental illnesses. "In fact, the
reverse has happened," Schroeder noted. "Discipline is easier when
cigarettes are out of the mix. Staff has more time to do therapeutic
However, psychiatrists and mental health professionals need to do more to
help patients in outpatient settings quit smoking, Schroeder asserted. Douglas
Ziedonis, M.D., who also participated in the teleconference as a commentator,
agreed. Ziedonis is chair of psychiatry at the University of Massachusetts and
an authority on the co-occurrence of mental illness and tobacco
First, even though recent surveys indicate that a number of mentally ill
patients would like to quit, some patients do not want to. That's where
psychiatrists and mental health professionals can step up: they need to
motivate patients to do so, Schroeder and Ziedonis stressed.
For example, Ziedonis said, he and his colleagues looked to see whether
several different techniques could motivate schizophrenia patients who did not
want to quit smoking to do so. One was helping them figure out how much of
their annual income they spend on smoking. In many cases, "over 25
percent was going up in smoke," he said. Another was using a carbon
monoxide breathalyzer to show them how carbon monoxide created by smoking was
robbing their bodies of much-needed oxygen and, in turn, impairing their
Both tools turned out to be valuable in changing patients' minds about
giving up smoking, he said—especially the breathalyzer. "People's
eyes lit up [when they saw their scores]," he said. "Those numbers
Second, to help outpatients quit smoking, psychiatrists and mental health
professionals need to be knowledgeable about the tools that can help them
achieve this goal, Schroeder and Ziedonis concurred.
These tools are essentially the same as those that can help mentally
healthy individuals quit smoking, Schroeder said. They are the telephone help
line at (800) QUIT NOW available to help people quit smoking; nicotine
replacement medications such as nicotine gum, patches, and lozenges;
bupropion, which is an approved prescription treatment not just for major
depression, but for tobacco dependence; and varenicline, which is a partial
nicotine agonist that diminishes the "hit" that a person gets from
cigarette smoke and which also lessens withdrawal symptoms from nicotine.
True, none of these treatments is a cure-all for mentally healthy persons,
Schroeder admitted. Trials have shown, for instance, that people who try to
quit smoking without any help succeed 3 percent of the time, while people who
get psychological counseling plus a medication such as nicotine replacement,
bupropion, or varenicline succeed 20 percent to 25 percent of the time. But
the crucial thing, he stressed, is that these treatments can clearly work in
helping smokers quit, and "there are now more ex-smokers in the United
States than current smokers," which should give hope to smokers who are
mentally ill that they too can quit.
Before prescribing medications to help patients quit smoking or before
encouraging patients to purchase over-the-counter alternatives, psychiatrists
and mental health professionals should be aware of some related issues,
Schroeder and Ziedonis cautioned.
For example, cutting back on smoking or stopping altogether may alter the
levels of psychotropic medications that patients need.
Varenicline, like bupropion, has been found to have a small suicide risk.
Or as Ziedonis put it: "In my own experience and also from having talked
with hundreds of psychiatrists who have used varenicline in both
smoking-cessation programs and in mental health settings, by and large the
medicine works very well.... But we do have to monitor patients and inform
them of the risk."
Data suggest that smoking-cessation medications are more effective in the
general population if used for more than 12 weeks than if they are used for
less than 12 weeks. So psychiatric patients may need to use them six, nine, or
even 12 months to obtain full benefit from them, Schroeder said.
In fact, even if psychiatric patients use such medications on a long-term
basis, it is clearly better than to continue smoking, he asserted, since the
health risks of the former are much lower than the health risks of the
"I had some patients who used nicotine gum for four, five, or six
years after quitting a couple-packs-of-cigarettes-a-day habit," Ziedonis
reported. "I agree with Schroeder,... but I think it is reasonable that
people would get off nicotine replacement at some time. You might view this as
a transitional tool to use for a year or so."
More information about Schroeder's center and ways to help patients
stop smoking is posted at<http://smokingcessationleadership.ucsf.edu>.▪