Psychiatrists Should Incorporate Smoking Cessation Into Practice

UCLA

An estimated 53 percent of patients with serious mental illness report regularly smoking tobacco cigarettes compared with 19 percent with no such illness. Despite the high prevalence of smoking in these patients and repeated calls by some psychiatrists to incorporate smoking cessation interventions into our practices, the application of smoking cessation treatments by psychiatrists remains inappropriately low.

In a recent review of nine community mental health sites, less than half of the clinicians reported asking their patients about smoking tobacco. Psychiatrists often conclude that patients with mental illness are not motivated to quit smoking, yet the data suggest these patients are just as motivated to quit smoking as smokers in the general population.

The United States Preventive Services Task Force recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. Psychiatrists, in particular, are in a good position to provide smoking cessation treatments to our patients. We generally have longer and more frequent appointments than our primary care colleagues and have specialized training in psychotherapy and psychopharmacology. Given that previous research suggests that tobacco-related conditions comprise approximately half of the deaths of patients with serious mental illness, smoking cessation is urgently required in psychiatric practice.

The pharmacotherapy of smoking cessation is straightforward and well described in the literature. In brief, nicotine replacement therapy (NRT), bupropion, and varenicline are all frontline pharmacotherapies for smoking cessation, with effect ratio compared with placebo reported to be, respectively, 1.6, 1.7, and 2.3.

• NRT should be prescribed at the equivalent dose of the amount of nicotine the patient consumes through smoke; one can generally estimate 1 mg of nicotine per cigarette smoked to calculate the NRT dosage. While NRT has a strong safety profile, it is associated with nightmares and insomnia if taken overnight and can cause site irritation at the point of contact with the body.

• Bupropion is recommended for smoking cessation at 150 mg sustained release once daily for one week and then increased to twice daily thereafter, although some clinicians uptitrate bupropion to 300 mg extended release once daily for smoking cessation. Bupropion is associated with insomnia, headaches, dry mouth, nausea, and anxiety. Bupropion is contraindicated for patients with current or previous seizure disorders, bulimia, and anorexia nervosa and those taking monoamine oxidase inhibitors.

• Varenicline is a high-affinity nicotinic receptor partial agonist, and therefore it is not prescribed in conjunction with NRT. Varenicline is typically initiated at 0.5 mg daily for three days, then 0.5 mg twice daily for four days, and then 1 mg twice daily thereafter.

Lastly, smoking increases hepatic clearance of many psychiatric medications via CYP P450 1A2 and 2E1, and therefore it is recommended that psychiatrists monitor serum levels and consider dosing adjustments of psychiatric medications at transition points where patients start or stop smoking tobacco.

SAMHSA has published an excellent resource describing psychosocial approaches to smoking cessation for people with mental illness, including treatment components for successful individual and group therapy. Psychiatrists are well served to use a combination of psychotherapy with motivational follow-up sessions to assess ongoing motivation for smoking cessation and engage cessation planning.

Given the rates of smoking and smoking-related health consequences in our patients, psychiatrists should be leading the delivery of smoking cessation interventions to our patients. Our patients are as motivated to quit as smokers in the general population, treatment is effective, and we have the skills to deliver high-quality smoking cessation care. ■