Why People with Mental Health Conditions Smoke So Much and What To Do About It John Hughes...
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Transcript of Why People with Mental Health Conditions Smoke So Much and What To Do About It John Hughes...
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Why People with Mental Health Conditions Smoke So Much and What To Do About It
John Hughes
University of Vermont, USA
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Disclosure
I have received grants, consulting fees or speaking fees from most of the priviate
companies, non-profits and governmental organizations prompting smoking
cessation devices, medication and services.
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Nicotine, The “Renaissance”Drug
• Relieves anxiety and depression
• Relieves anger
• Improves concentration
• Decreases hunger
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What Are the Problems Facing 16 yr Olds?
• Controlling mood
• Controlling anger
• Concentrating
• Controlling weight
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• Occurs quickly after the behavior
• Frequent self-administration
• Effects occurs reliably
• No intoxication
• Requires few skills to obtain
Nicotine Via Cigarettes is the Perfect Reward
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No disorder 43%
Major depression 38%
Anxiety disorders 33%
Alcohol/Drug 29%
Schizophrenia 27%
Bipolar 17%
Lifetime Smoking Cessation Rates by Psychiatric Disorder (Lasser 99)
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Cause of Death in Recovering Alcoholics
Alcohol Tobacco Other0
20
40
60
80
100
120
Hurt et al, 1995
Att
rib
uta
ble
D
eath
s
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Expenditures on Tobacco
• Smokers with schizophrenia spend 27% of income on tobacco
• Cf: In US, 20% spent on housing and 10% spent on food
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Casual Flow of Depression and Smoking
(Breslau 1991)
• Depression predicts progress to daily smoking OR = 3.0
• Smoking predicts onset of depression OR = 1.9
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Smokers with vs without Mental Health Conditions
• Fewer neversmokers (20% vs 55%)
• Fewer exsmokers (10% vs 25%)
• Fewer quit attempts (15% vs 45%)
• Less success when try to quit (10% vs 15%)
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Ever Quit =
Success/Quit Attemptx
Number of Quit Attempts
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The lower rate of lifetime cessation is as much due to
fewer quit attempts as to less success on a given attempt.
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Examples of How Smoking Interacts with Dx and Tx of
Mental Health Disorders
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Hints for Smoke-Free Facilities
• Explain rationale
– to decrease second hand smoke – to decrease initiation or relapse among never
or former smokers on ward– not to pressure you to quit
• Treat withdrawal with NRT
• Predicted disasters do not occur
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Nicotine Withdrawal
• Anxiety• Restlessness• Irritability• Difficulty concentrating• Hunger/weight gain• Insomnia• Depressed mood• Decreased heart rate
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Overlap in Nicotine Withdrawal and Mental Health
Diagnosis and Tx
Symptom Diagnosis
Irritability Drug withdrawalInsomnia Several disordersRestlessness AkathesiaWeight gain TCA side-effects
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Smoking Abstinence Increases Drug Blood Levels
Fluphenazine Fluvoxamine Haloperidol Imipramine Oxazepam
CaffeineClomipramineClozarilClozapineDoxepin
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0
20
40
60
80Blood Levels by Smoking Status
Smokers Nonsmokers Smokers Nonsmokers
Clozaril Fluvoxamine
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Mental Health Disorder
General population
Pre-contemplation
43% 57%
Contemplation 38% 33%Preparation 19% 10%
Interest in Quitting Smoking
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Interest in Quitting Smoking Among Those with Alcohol Problems
(Hall, 09)
• 44% - 80% want to quit in near future
• 25% want to stop concurrent with stopping alcohol
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Ever Quit =
Number of Quit Attemptsx
Success/Quit Attempt
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Lay Explanations of Behavior Change
• Cathartic event
• Sudden insight
• Large contingency
• Solid decision to change: “Just Do It”
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Effect of Cumulative EventsScenario 1
Clinician Kids UncleAdvice Cough complain Embarrassed Dies
Precontemplation Contemplation Preparation
1 Year
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Effect of Cumulative EventsScenario 2
Uncle Kids ClinicianDies Cough Complain Embarrassed Advice
Precontemplation Contemplation Preparation
1 Year
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Effect of Not Presenting Cue
• When MDs do not mention smoking, smokers conclude – My use is not that problematic – The MD does not think I can change
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Tips for Treating Smoking in Those with Mental Health Conditions
•Keep smoking cessation on problem list
•Motivate every few months using personal risks and discussing barriers
•Let patient decide timing
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Prompting Quit Attempts
• Best done when less symptomatic • Set up as natural progression from conquering
one problem to taking on another one• Emphasize many quit without mental health
conditions
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Addressing Smoking in People with Mental Health Conditions
• 90% of effort is prompting quit attempt
• 90% of time not be successful
• 90% of time will take several prompts
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Relapse Curve in Self-Quitters
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Proven Treatments • Behavioral Therapies
– Quitlines
– Groups
– Individual
• Medications
– Nicotine gum, inhaler, lozenge, patch, combinations
– Bupropion
– Varenicline
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Behavioral Treatments
• Usually increase quitting by 1.5x
• Quitlines effective – but used by < 5%
• Group and individual effective but rarely available
• Internet and social media effective
• No recent progress in improving outcomes
• No reimbursement
• Few trained therapists
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New Behavioral Treatments
• Mindfulness
• Acceptance Therapy
• Behavioral Activation Therapy
• Persistence Therapy
• Exposure Therapy
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ORs for Effect of Proven Medications
Nicotine gum 1.7
Nicotine patch 1.7
Nicotine inhaler 2.1
Nicotine lozenge 2.1
Combined NRTs 2.4
OTC NRT 2.0
Bupropion 2.1
Varenicline 2.8
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Better Use of Treatment
• Combined patch + ad lib NRT or Varenicline is
first line tx
• Pre-treatment
• Extended Treatment
•Continued use after a lapse
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Other Medication Treatments Under Study
• Mouth spray• Faster oral NRT• Snus• True nicotine inhalers• Non-nicotine cigarettes• Cytisine • Sensory replacement• Vaccine
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Varenicline and Psychological Adverse
Events
• Based on case reports
• Not found in meta-analysis of 39 trials
• Not found in five large real world data sets (total n > 55,000)
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Types of Treatments Used
• No treatment 63%
• OTC Medications 25%
• Rx Medications 8%
• Talking tx 2%
• Internet 2%
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Incidence of Treatment Use
• Smoking 25-35%
• Depression 25-50%
• Alcoholism 10-12%
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Percent of Quit Attempts That are Unplanned
Larabie, 2005 52%
West, 2000 49%
Fergusen, 2009 40%
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2/3rds of Rxs for varenicline are patient initiated
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Non-Cessation Indications
• Reduction as preliminary to abstinence
• Reduction to reduce harm
• Withdrawal relief during temporary abstinence
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Reduction in Unmotivated Smokers
No Tx Reduction Motivational
Quit Attempt 16% 43% 51%
6 Mo Quit 4% 18% 23%
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Reduce-to-Quit
• Gradual cessation is common (35-60% of attempts)
• RTQ approved in many European countries and Canada
• Unlikely to be approved in US anytime soon
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Tips for Treating Smoking in People with Mental Health
Conditions
•Tailored or more intensive treatment not essential
• Neither therapy nor meds are essential
•Monitor weekly to prevent remission of alcohol / drug problem
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Tips for Treating Smoking in Those with Mental Health
Disorder
• Therapists already have many of the skills needed, only brief training needed for most clinicians
• Associate with nonsmoking friends
• Buddy systems with ex-smokers
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Does Cessation Precipitate Psychiatric Relapse?
• 0-18% of smokers with past history of MDD relapse during abstinence
• The mental health of most smokers improves with abstinence
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Long-term Effect of Smoking Cessation
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Long-Term Effect of Cessation
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Tips for Motivating Cessation in Patients with Mental Health
Conditions
• Combat prior messages that patient lacks ability to quit
•Consider small steps: e.g. reduction
• Reduction may not reduce health risks but does increase later quitting
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Tips for Treating Smoking in People with Mental Health
Conditions• Recommend proven therapies
• Not necessary to use tailored or more intensive treatment
• Monitor closely to prevent remission of mental health condition
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Summary
• Nicotine produces psychological benefits
• Smokers with mental disorders often die from smoking-related illnesses
• Those with mental disorders more likely to start and less likely to quit smoking
• Increasing quit attempts as important as, if not more important than, aiding quit attempts
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Summary
• Social support, especially from peers, important
• May want to begin with reduction goal
• Mental health clinicians have many of the skills need to motivate and help smokers quit
• Acquiring expertise is easy
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Summary
• May not need tailored or more intensive treatment
• Abstinence symptoms can mimic psychological symptoms
• Abstinence can change levels of psychiatric medications
• Abstinence may increase relapse of mental disorder in small minority
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Association for the Treatment of Tobacco Use and Dependence
An organization of providers dedicated to the promotion of and increased access to evidence-based tobacco treatment for the
tobacco user.
www.attud.org