People With SMI Can Be Helped to Quit Smoking

Erin Gaudette and Tony George, M.D.

People with serious mental illness (SMI) have higher rates of smoking than the general population. While some estimates suggest approximately 20 percent of adults in the United States are smokers, more than half of patients with SMI are believed to smoke tobacco (1). What medications are available to help these patients reduce tobacco use?

In 2006, the Food and Drug Administration approved the nicotinic partial agonist varenicline (Chantix; Champix) as a first-line treatment for tobacco use disorder (joining sustained-release bupropion and nicotine replacement therapies as possible options for treatment). Varenicline supports both smoking cessation and prevention of smoking relapse by attenuating craving and withdrawal symptoms. Several studies have since examined the efficacy of varenicline in populations with serious mental illness.

One randomized, controlled trial compared the effectiveness of varenicline with placebo in smokers with schizophrenia or schizoaffective disorder. The study found that after 12 weeks on varenicline (2 mg/day), 19 percent of varenicline-treated patients met smoking cessation criteria, compared with 4.7 percent in the placebo group. Total adverse-event rates were similar between groups, with no significant changes in symptoms of schizophrenia or in mood and anxiety ratings (4).

Another trial found that significantly more patients with bipolar disorder quit smoking after taking varenicline for three months than those who took placebo (48.4 percent versus 10.3 percent, respectively). At six months, 19.4 percent of the varenicline-treated patients remained abstinent compared with 6.9 percent assigned to placebo (5).

Studies also suggest that maintenance varenicline delays relapse to smoking when combined with cognitive-behavioral therapy. A 2014 study in JAMA found that point-prevalence abstinence at one year was three times higher among patients with SMI who were assigned to maintenance varenicline treatment (60 percent) than among those assigned to placebo (19 percent) (6). As with the other varenicline trials of people with SMI, there were no significant differences between the two groups in psychiatric symptom ratings or psychiatric adverse events.

Varenicline is not the only medication that may help to reduce smoking in SMI patients. A recent study (EAGLES Trial) compared the safety and efficacy of the three major front-line treatments for nicotine dependence (varenicline, bupropion SR, and nicotine replacement therapy as patch) in patients with and without psychiatric disorders.

The study found that patients with psychiatric disorders who took varenicline for 12 weeks achieved higher rates of abstinence compared with those taking bupropion SR (300 mg/day), nicotine patch (21 mg/day), or placebo. Those on bupropion and nicotine patch achieved higher abstinence rates than those on placebo.

Patients taking varenicline and bupropion were not found to have a significant increase in the number of neuropsychiatric adverse events (7). While the findings suggest that smoking cessation medications are safe and effective, more research is needed, as most participants had major depression, anxiety, and personality disorders rather than SMI, and the study was funded by Pfizer and GlaxoSmithKline.

While all three first-line pharmacotherapies appear to be useful in helping people with SMI to abstain from smoking, varenicline may be the most effective.

Neuroscience-based approaches for the treatment of refractory tobacco use disorder in SMI patients may hold promise for improving cessation from tobacco and quality of life for these vulnerable patients. Such treatments include repetitive transcranial magnetic stimulation (rTMS) to the dorsolateral prefrontal cortex in schizophrenia (8) and the use of alternative products such as e-cigarettes and very low nicotine cigarettes (3). ■