Review
Smoking, quitting, and psychiatric disease: A review

https://doi.org/10.1016/j.neubiorev.2011.06.007Get rights and content

Abstract

Tobacco smoking among patients with psychiatric disease is more common than in the general population, due to complex neurobiological, psychological, and pharmacotherapeutic mechanisms. Nicotine dependence exposes smokers with co-occurring mental illness to increased risks of smoking-related morbidity, mortality, and to detrimental impacts on their quality of life. The neurobiological and psychosocial links to smoking appear stronger in certain comorbidities, notably depression and schizophrenia. Through its action on the cholinergic system, nicotine may have certain beneficial effects across a range of mental health domains in these patients, including improved concentration and cognition, relief of stress and depressive affect, and feeling pleasurable sensations. Despite the availability of effective smoking cessation pharmacotherapies and psychosocial interventions, as well as increasing evidence that individuals with psychiatric disorders are motivated to quit, nicotine dependence remains an undertreated and under-recognized problem within this patient population. Evidence suggests that provision of flexible and individualized treatment programs may be successful. Furthermore, the complicated relationship observed between nicotine dependence, nicotine withdrawal symptoms, and mental illness necessitates integration of close monitoring in any successful smoking cessation program.

Highlights

• Smoking in patients with psychiatric disease is more common than in the general population. • Neurobiological links to smoking seem strongest in smokers with depression and schizophrenia. • There is a complex relationship between mental illness and nicotine dependence and withdrawal. • Nicotine dependence is undertreated among smokers with psychiatric disease. • Flexible, individualized smoking cessation programs may be successful in this patient population.

Introduction

The detrimental health effects of smoking were first reported in 1950 when the behavior was established as a cause of lung cancer (Doll and Hill, 1950). Since then, there have been a large number of studies showing the widespread and serious health consequences of tobacco smoking, and the issue has been addressed in 30 U.S. Surgeon General Reports on smoking published between 1964 and 2010. The 1979 Surgeon General Report defined smoking for the first time as nicotine addiction, and the 1988 Report concluded that “the pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine” (U.S. Department of Health and Human Services, 1988). Tobacco dependence is now acknowledged as a chronic condition that accounts for nearly half a million premature deaths each year in the U.S. alone (CDCP, 2005, Fiore et al., 2008). Furthermore, the global health burden of cigarette smoking is huge, with the recent incidence of smoking-related mortality being estimated at over 5 million people annually and predicted to increase to approximately 1 billion smoking-related deaths during the twenty-first century (Jha, 2009).

While all smokers risk tobacco-associated morbidity and mortality, the close and complex relationship between smoking and psychiatric disorders exposes smokers with mental illness to increased smoking-related risks. For instance, the prevalence of cigarette smoking is significantly higher among patients with psychiatric illnesses than among the general population (de Leon et al., 1995, Grant et al., 2004, Lasser et al., 2000, Lising-Enriquez and George, 2009, Pomerleau et al., 1995).

Based on the 2001–2002 sample from the National Epidemiologic Survey on Alcohol and Related Conditions in the US (US-NESARC), it is estimated that between 21% and 31% of individuals with a current nicotine dependence also have a current mood, anxiety, psychiatric, or alcohol use disorder and that nicotine-dependent psychiatric patients, although they made up 7% of the population, consume about 34% of all cigarettes smoked in the U.S. (Grant et al., 2004). The lifetime smoking rate in patients diagnosed with a psychiatric disorder in the previous month was even higher at 59% (Lasser et al., 2000). In certain specific diagnostic groups, very high smoking prevalence rates have been estimated, such as 60.6% for bipolar disorder (Lasser et al., 2000) and 65–90% for schizophrenia (Kalman et al., 2005, McCreadie, 2002, Williams and Ziedonis, 2004).

Psychiatric patients experience combined factors that together increase the impact of smoking in this group compared with non-psychiatric groups. For example, individuals with depression and schizophrenia have been observed to have higher mortality rates from vascular disease and a greater prevalence of cancers (Hennekens et al., 2005, Kisely et al., 2008). Additional negative consequences arise from the close link between smoking prevalence and mental health disorders, such as poorer overall health (Pack, 2009), higher levels of non-compliance with drug regimens (Marder, 2003, Taj and Khan, 2005), and suboptimal cardiovascular care (Hennekens et al., 2005). Many individuals with a serious mental illness are already financially compromised and this is only worsened by their addiction to cigarettes; for instance, smokers with schizophrenia were found to spend almost 30% of their income (mainly received from public assistance) on cigarettes each month (Steinberg et al., 2004). There is also evidence that psychiatric patients with nicotine dependence are more likely to have a lower social status than psychiatric patients who are not nicotine dependent (Montoya et al., 2005) and that in adolescents there is a higher incidence of illicit drug use among those who smoke compared with those who do not smoke (Brown et al., 1996).

Another important issue complicating the assessment of smoking behaviors and initiation of cessation in smokers with psychiatric illnesses relates to periods of hospitalization because during periods of inpatient treatment smoking habits can change, which in turn can alter the presentation of their psychiatric disorder and its pharmacological treatment (Olivier et al., 2007). In addition, staff often use cigarettes to reinforce certain behaviors in the inpatient setting leading to some alterations in social interactions focused around smoking, thus it is important to address staff concerns about smoking cessation in psychiatric units (Olivier et al., 2007). A further issue that has created a barrier to tackling smoking in psychiatric populations is the hypothesis that smoking is a form of ‘self-medication’ for certain psychiatric symptoms, which may discourage clinicians from promoting smoking cessation in their patients and reduce the understanding of nicotine dependence in this population (Ziedonis et al., 2008). Indeed, smoking has for many years been tolerated and, in some ways, encouraged by the mental health treatment community (Schroeder and Morris, 2010).

Unfortunately, it appears that the difference in smoking prevalence among those with and without psychiatric illness is widening. Successful antismoking campaigns and smoking cessation programs have helped reduce the proportion of smokers in the general population of Western Countries from 45% in the 1960s to between 23% and 30% in the 2000s, but many patients with psychiatric illness keep smoking (Adams and Stevens, 2007, Andreas and Loddenkemper, 2007, de Leon et al., 1995, Dervaux and Laqueille, 2008). For example, in the 2007 U.S. National Health Interview Survey smoking prevalence in adults with mental illness ranged from 34% for those with phobias and fears to 59% for those with schizophrenia versus 18% for adults with no mental illness (McClave et al., 2010). The health benefits of stopping smoking are immediate and long-lasting (U.S. Department of Health and Human Services, 1990). Treating smoking and smoking-related problems in psychiatric patients is therefore an important responsibility of mental health clinicians and primary care physicians. Furthermore, mechanisms involving both neurobiological and psychological elements have been identified as contributors to higher smoking prevalence among individuals with mental health disorders (Morisano et al., 2009), but the negative health impact of smoking in psychiatric patients is often under-recognized and undertreated.

Section snippets

Underlying mechanisms of nicotine dependence

Nicotine (or tobacco) dependence is an addiction to tobacco products characterized by tolerance and withdrawal symptoms that are associated with the pharmacological effects of nicotine; the 1988 Surgeon General Report lists the three primary criteria for drug dependence, including nicotine dependence as: highly controlled or compulsive use, psychoactive effects, and drug-reinforced behavior (U.S. Department of Health and Human Services, 1988). Although tobacco products contain over 4000

Association between nicotine dependence and psychiatric disorders

Among the mentally ill, smoking prevalence is highest in patients with schizophrenia (∼70–90%), which approximates to three times the rate of the general population (Andreas and Loddenkemper, 2007, Dalack et al., 1998, de Leon et al., 1995, Williams and Ziedonis, 2004). In a meta-analysis of 42 studies conducted in 20 countries, there was a consistent association between schizophrenia and current smoking, which remains even when smokers with schizophrenia are compared with smokers with other

Role of nicotine on cognition and mood in psychiatric disorders

The high incidence of smoking among psychiatric patients might in part be due to a beneficial effect of nicotine on cognition and/or mood. For example, a growing body of evidence suggests that patients with schizophrenia may derive improvement in some areas of cognitive performance after smoking cigarettes or using a nicotine replacement therapy (NRT) (Adler et al., 1993, Barr et al., 2008b, Harris et al., 2004, Jacobsen et al., 2004, Levin et al., 1996, Levin et al., 2001, Smith et al., 2002).

Impact of smoking behavior on psychiatric medications

Smoking impacts the course of psychiatric disorders through its profound effect on the metabolism of psychotropic drugs and is thus a contributory factor to the individual variations observed in drug responses (Wu et al., 2008). Nicotine metabolism is mediated primarily by the cytochrome P450 1A2 (CYP1A2) and by CYP2A6.

Since many psychiatric drugs, including diazepam, haloperidol, olanzapine, clozapine, fluphenazine, and mirtazapine, are also metabolized through CYP1A2 induction, smoking can

Impact of psychiatric disorders on smoking behavior

Smoking appears to be more rewarding for psychiatric patients; for example patients with schizophrenia or depression given a choice of ‘pleasant activities’ selected smoking twice as often and attributed greater benefits and reward value to smoking compared with patients without psychiatric disorders (Spring et al., 2003). Although these psychiatric patients acknowledged the potential drawbacks of smoking, its perceived advantages were considered to be so great that any approach to quit would

Smoking cessation treatment options

The updated 2008 practice guidelines published by the U.S. Department of Health and Human Services recommend that smokers with mental health problems should be treated with the same smoking cessation strategy as the general population, with particular encouragement of the need for clinicians to treat this population group (Fiore et al., 2008).

The U.S. Clinical Practice Guidelines provide practical clinical recommendations to achieve effective smoking cessation in all individuals who use tobacco

Potential future approaches to smoking cessation in psychiatric patients

One factor associated with the slow progress for evaluating novel pharmacotherapies in the psychiatric population is the scarcity of smoking cessation trials of existing treatments involving this group of patients (Hitsman et al., 2009). As noted previously, there are only a few published trials evaluating NRT, bupropion SR, or varenicline in smokers with psychiatric disorders, although some new trials are underway in specific psychiatric populations.

Changes in the delivery and duration of

Discussion

Recognizing tobacco use as an addiction is critical both for treating the patient and for understanding why people continue to use tobacco despite the known health risks (Fiore et al., 2008). This is particularly important for smokers with psychiatric disorders because for many years smoking has been tolerated in this group (Schroeder and Morris, 2010) and has even been viewed as a normal self-medication behavior by members of the mental health treatment community (Ziedonis et al., 2008).

Financial disclosures

None of the authors received funding for the development of this manuscript.

Henri-Jean Aubin has received sponsorship to attend scientific meetings, speaker honorariums, and consultancy fees from Pfizer, McNeil, GlaxoSmithKline, Pierre-Fabre Sante, Sanofi-Aventis, Lundbeck, and MerckSereno.

At the time of the CINP 2009 satellite symposium and when this review article was first written, Hans Rollema was an employee of and stockholder of Pfizer, Inc.

Torgny H. Svensson has received grants, as well

Acknowledgements

The contents of this review article were presented in part by the authors at a Satellite Symposium at the Collegium Internationale Neuro-Psychopharmacologicum (CINP) International Thematic Meeting, which took place April 25–27, 2009 in Edinburgh, Scotland. The symposium was entitled “The Links between Smoking and Psychiatric Disease: What can be done to help?” The authors would like to thank the Chairman of the symposium – Prof. Wolfgang Fleischhacker – for his encouragement to publish the

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