Tobacco Addiction, Treatment Need More Attention by Clinicians

The American Society of Addiction Medicine’s criteria for addiction covers “all types of addictive substances from A to Z—except T,” said Jill Williams, M.D., a professor of psychiatry and director of the Division of Addiction Psychiatry at the Robert Wood Johnson Medical School in New Brunswick, N.J.

Aaron Levin

The “T,” she reminded attendees last month at IPS: The Mental Health Services Conference, stands for the most common and most easily obtainable addictive substance: tobacco.

“The fast uptake by way of smoking and the short half-life of nicotine means there is a need to smoke every few hours,” she said. “True, there is no acute intoxications effect, but the withdrawal symptoms are significant and lead to complications and relapse.”

Cigarette smoke’s dangers go beyond nicotine. It contains 7,000 chemicals including at least 65 carcinogens, she said. Smoking complicates pregnancy and increases general morbidity.

Both specialists and the public undervalue tobacco use as a problem, said Williams. Treatment is complicated by limited knowledge among clinicians about the effectiveness of treatment and by poor reimbursement.

“What is needed are expanded levels of care, increased reimbursement, and better access to medications,” said Williams.

Of particular concern to psychiatrists is the fact that while the overall number of individuals who smoke has declined in the United States, it has not declined among people with mental illness. One-third of people with severe mental illness smoke, and tobacco is responsible for 50 percent of the deaths among those individuals, she said. “If you smoke today in the United States, you are very likely to have a mental illness or be very poor.”

At the same time, the attitude of the addiction community remains puzzling, said Williams. Patients arriving at residential drug treatment facilities may be forbidden to bring in books, but they can possess cigarettes—which are often considered a coping mechanism. The least likely places to provide tobacco treatment are private, for-profit facilities, she said. “Addicts go where they can use drugs.”

Treatment is too often minimal. The most common treatment for tobacco addiction is also the least effective: pamphlets, nicotine patches, and going “cold turkey.”

Barely half a step up from that level are the brief interventions found in outpatient primary care. Medicare pays $12.89 for a three-to-10-minute effort and $23.99 for more than 10 minutes. Medicaid, the single largest payer for mental illness care, has low reimbursement rates for smoking cessation and limits on treatment. Other barriers to care include copays, prior authorization requirements, and time and money limits. Residential care is more effective but rare.

Nevertheless, treatment pays off, she said. It can save lives from heart attacks and other acute cardiovascular conditions. In addition, a dollar of care provides a $2.12 return on investment to the Medicaid program, although it takes three years for that payoff to occur.

“Behavioral health professionals should take the lead in tobacco treatment,” said Williams. Tobacco dependence is a DSM-5 diagnosis, plus clinicians are trained to treat addiction and are experts in counseling.

“When people get tobacco treatment, it’s usually low-intensity treatment regardless of how sick they are or the severity of their dependence or their biopsychosocial circumstances,” she said. That is quite different from other addiction care in which a range of treatment responses is available.

For Williams, an ideal Medicaid benefit would include coverage of all seven FDA-approved medications for tobacco treatment: bupropion SR, nicotine gum, nicotine inhaler, nicotine lozenge, nicotine nasal spray, nicotine patch, and varenicline.

“Combinations of these drugs should not be banned,” said Williams. “There is evidence that combining two nicotine-replacement medications is more effective than one.”

Care should not be delayed by prior authorization, time limits on treatment, or requirements for stepped care or counseling, she said. Patients should have access to several courses of medications and multisession counseling each year. Copays should be eliminated or at least reduced significantly.

Intensive outpatient treatment by a psychiatrist can improve management of co-occurring psychiatric illnesses and simplify prescribing of medications.

“The main goal should be to help patients who have ongoing problems achieving abstinence, complicated biomedical and behavioral conditions, or limited support in the community,” she said. ■