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
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]
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
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
"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
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
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,
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 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
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
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
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
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
"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.