Psychiatrists Hold Key for Helping Patients Quit Tobacco

Tobacco use is the leading cause of preventable death in the United States, yet it remains a largely “forgotten addiction,” Smita Das, M.D., Ph.D., M.P.H., said at a session on tobacco use disorder at APA’s Annual Meeting in May. In fact, tobacco use causes 480,000 deaths a year in the United States alone, eclipsing deaths from motor vehicle accidents, firearms, suicide, opioid overdoses, and AIDS combined, said Das, who is a clinical assistant professor at Stanford School of Medicine.

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Tobacco use takes a particularly heavy toll on those with current mental illness or substance use disorders: Smoking is two to four times more prevalent in this patient population and one of the main reasons for their decades-shorter lifespans compared with the general population, she said.

Psychiatrists are well positioned to encourage tobacco cessation among their patients, but evidence suggests they’re missing the opportunity. An American Association of Colleges survey found that psychiatrists were least likely to address tobacco use with their patients compared with physicians in family medicine, internal medicine, or obstetrics-gynecology. Why?

For some, it’s not entirely clear where tobacco cessation treatment falls, said Das. Is it under the purview of psychiatry or general medicine? And from a training perspective, nicotine addiction is insufficiently addressed during the one month of substance use disorder training psychiatrists typically receive, she said.

Das added that many psychiatrists historically have consciously postponed treating patients with tobacco use disorder until after resolving other psychiatric and substance use disorders out of fear that addressng tobacco cessation would jeopardize a patient’s primary treatment goals. Increasingly, evidence suggests the contrary. In fact, tobacco cessation treatments result in better mental health outcomes overall.

In addition, multiple studies have shown that patients with a variety of mental illness diagnoses are just as ready to kick the habit as those in the general population, explained Douglas Ziedonis, M.D., M.P.H., an associate vice chancellor for health sciences and a professor of psychiatry at the University of California, San Diego. Up to 28% of patients being treated for a psychiatric condition said they intended to quit within the next 30 days (compared with 20% in the general population), and as many as 55% said they intended to quit in the next six months (compared with 40% in the general population).

Ziedonis added that patients with a psychiatric illness generally experience worse nicotine withdrawal symptoms and therefore need more help to get through the period when withdrawal is most intense, typically the first four to six weeks.

Nicotine withdrawal symptoms such as depression, insomnia, irritability/anger, anxiety, difficulty concentrating, restlessness, and increased appetite peak one to two days after a quit attempt and may be more likely to discourage psychiatric patients, Das added. Patients may incorrectly conclude that tobacco use is helping to control their psychiatric illness, she said. “But it’s not. The nicotine use is treating only their nicotine withdrawal symptoms.”

“There is evidence that when psychiatric patients are offered assistance with quitting, they can be successful, too,” said Ziedonis. Compared with smokers who received no assistance, smokers who got help from their physician were more than twice as likely to quit smoking successfully for five or more months, one study found. Yet there is much room for improvement within the mental health community: Just 1 in 4 mental health treatment facilities surveyed offer services to help patients quit smoking, according to findings from the 2014 National Mental Health Services Survey, a statistic that has not changed since the 2010 survey.

Pharmacotherapy for Tobacco Cessation Can Help Patients

Medications should be a routine part of treatment for tobacco use disorder, according to Andrew Saxon, M.D., a member of APA’s Council on Addiction Psychiatry. Rx for Change, a free tobacco cessation training program created by the University of California, San Francisco, trains medical professionals on how to incorporate tobacco cessation medications into their practice to help patients quit for good. Approved medications include the following:

• Nicotine-replacement therapies (NRT)—which include short-acting gum, lozenges, an inhaler, a nasal spray, and long-acting transdermal patches—reduce nicotine withdrawal symptoms, giving the patient a chance to focus on the behavioral and psychological aspects of tobacco cessation. Das pointed out that patients using NRTs should refrain from all smoking. Saxon cautioned that NRTs are not appropriate for patients with underlying cardiovascular disease. He added that patients using nicotine gum for the first time need guidance on how to do so correctly to avoid side effects.

• Bupropion (Zyban), a norepinephrine-dopamine reuptake inhibitor that reduces both the craving for cigarettes and symptoms of nicotine withdrawal, can be used in conjunction with an NRT. Saxon said the medication should be started one week prior to a quit attempt and avoided in patients with an increased risk for seizures.

• Varenicline (Chantix) is a low-level agonist that inhibits the binding of nicotine. Saxon said it blocks the reward response that reinforces smoking, offering a new mechanism of action for patients who have failed on other tobacco cessation medications. Patients begin varenicline therapy one week prior to quitting, and up to one-third of patients may experience nausea, Saxon said.

Rx for Change: Follow the Five A’s

Rx for Change offers a training program specifically tailored for psychiatrists. It advises asking patients about nicotine use at all encounters but also stresses the importance of letting patients guide the process, Das said. “Don’t force them into what you want for their quit plan. Let it be their quit plan.”

Rx for Change espouses the “5 A’s” to help patients successfully quit using tobacco:

• Ask patients about tobacco use at every visit.

• Advise tobacco users to quit by using clear, strong, personalized messages such as “It’s important that you quit as soon as possible, and I can help you.”

• Assess and document patients’ readiness to make a quit attempt regularly.

• Assist patients in their quit attempts by providing motivation, setting a quit date, designing a treatment plan, engaging in brief counseling, providing medication counseling and coping strategies, and discussing relapse prevention.

• Arrange follow-up care. One study found that patients who receive zero to one follow-up visit when quitting tobacco had a 12% success rate; the success rate jumped to 25% for those who received more than eight follow-up visits. Medicare as well as some insurance providers may cover tobacco cessation counseling, Saxon advised.

Ziedonis also incorporates carbon dioxide meters in his practice for patients who smoke. He said the device is relatively inexpensive and easy to use: Patients just breathe into a mask.

“Carbon dioxide meters can help patients understand that they may be breathing in far more carbon dioxide than they realize and that it stays in their bloodstream longer than they realize,” he said. “It’s a very powerful tool to help patients become motivated as well as to track their progress over time.” ■