Elsevier

Addictive Behaviors

Volume 29, Issue 6, August 2004, Pages 1067-1083
Addictive Behaviors

Addressing tobacco among individuals with a mental illness or an addiction

https://doi.org/10.1016/j.addbeh.2004.03.009Get rights and content

Abstract

Tobacco dependence among individuals with a mental illness or an addiction is a tremendous problem that goes largely ignored. Studies of genetics, neuroimaging, and nicotinic receptors support a neurobiological link between tobacco use and alcohol dependence, drug dependence, schizophrenia, depression, attention-deficit hyperactivity disorder (ADHD), and anxiety disorders. This paper summarizes the recent literature on this topic and discusses how treatment for tobacco can no longer be ignored in mental-health and addiction-treatment settings. More research is needed as well as a national organized effort to address tobacco in this large segment of smokers.

Introduction

Tobacco dependence among individuals with a mental illness or an addiction is a tremendous problem that goes untreated and ignored and contributes to excesses in morbidity and mortality that are largely preventable. Research suggests strong clinical associations and shared neurobiological findings which link these disorders. This paper attempts to increase the addiction specialists' knowledge and interest in addressing tobacco in this important subgroup of tobacco-dependent smokers.

In addition to biological factors, social and psychological factors are also important in understanding tobacco dependence in this population. Smoking has become an accepted part of the culture in most mental-health and substance-abuse treatment centers and residential facilities. Historically, smoking has been used as a behavioral reward in psychiatric inpatient units and continues to serve as a shared social activity for many psychiatric patients. Patients coping with persistent symptoms and reduced social and occupational functioning often resort to smoking to fill the voids of boredom and loneliness. However, for persons with a mental illness or addiction, tobacco use can be an additional barrier to achieving relationships, employment, housing, and other mainstream activities.

This paper begins with a review of relevant clinical epidemiology and neurobiological findings by specific subtypes within the target population (e.g., “schizophrenia and tobacco dependence” or “alcohol dependence and tobacco dependence”). It then discusses issues related to treatment as well as the systems and policy issues that need to be addressed to further work in this area.

We recognize that although behavioral health disorders (mental illness and addiction) are a heterogeneous group, with differing etiologies, genetics, and clinical aspects that make some generalizations difficult, there are, however, policy and treatment directives that can benefit the group as a whole.

Section snippets

Part I. Review of clinical epidemiology and neurobiology: Increased prevalence of tobacco use

We know that 50–90% of individuals with mental illness or addiction are tobacco dependent and that rates vary according to co-occurring disorder diagnosis and setting of the study. A recent article in the Journal of the American Medical Association reported that 44% of the cigarettes smoked in the United States are by individuals with a psychiatric or substance-abuse disorder (Lasser et al., 2000). Similarly, other studies have reported that this population is two to three times more likely to

Part II. Clinical and systems issues

Despite the scope of this problem, tobacco use is largely ignored, delayed, or discouraged in the mental-health and addiction-treatment settings Foulds, 1999, Rustin, 1998. Many still do not see tobacco dependence as a disorder like other mental illnesses or addictions. Most have had limited training in addressing tobacco and have limited knowledge about nicotine neurobiology. Treatment settings have promoted the use of cigarettes as a behavioral reinforcement to reward appropriate behaviors.

Conclusion

Tobacco addiction in individuals with mental illness or an addiction can no longer be ignored. We cannot allow stigma to block our efforts to apply effective public health and clinical treatment approaches to the leading cause of death and morbidity for this population. We also cannot collude with the common beliefs that smoking is a necessary part of having a mental illness or addiction, or that patients are not interested in quitting or the ability to quit. Recent studies suggest that

Acknowledgements

This work is supported in part by a grant from the National Institute on Drug Abuse (NIDA K-DA14009-01 for J.W.). Dr. Ziedonis is receiving research grant support from Janssen, Bristol-Myers Squibb, Astra-Zeneca, and Lilly Pharmaceutical. He is also receiving research grant support from the Center for Substance Abuse Treatment, the National Institute of Drug Abuse, and the Robert Wood Johnson Foundation. Both authors are also supported in part by the New Jersey Department of Health and Senior

References (110)

  • J.B. Lohr et al.

    Smoking and schizophrenia

    Schizophrenia Research

    (1992)
  • J. McEvoy et al.

    Clozapine decreases smoking in patients with chronic schizophrenia

    Biological Psychiatry

    (1995)
  • J.P. McEvoy et al.

    Smoking and therapeutic response to clozapine in patients with schizophrenia

    Biological Psychiatry

    (1999)
  • M.A. Menza et al.

    Smoking and movement disorders in psychiatric patients

    Biological Psychiatry

    (1991)
  • C.J. Murray et al.

    Global mortality, disability, and the contribution of risk factors: Global burden of disease study

    Lancet

    (1997)
  • H.T. Nagamoto et al.

    Gating of auditory P50 in schizophrenics: Unique effects of clozapine

    Biological Psychiatry

    (1996)
  • A. Olincy et al.

    Increased levels of nicotine metabolite cotinine in schizophrenic smokers compared to other smokers

    Biological Psychiatry

    (1997)
  • R. Pohl et al.

    Smoking in patients with panic disorder

    Psychiatry Research

    (1992)
  • M.A. Prendergast et al.

    Chronic nicotine exposure reduces N-methyl-d-aspartate receptor-mediated damage in the hippocampus without altering calcium accumulation or extrusion: Evidence of calbindin-D28K overexpression

    Neuroscience

    (2001)
  • M.S. Reid et al.

    An acute dose of nicotine enhances cue-induced cocaine craving

    Drug and Alcohol Dependence

    (1998)
  • P. Seth et al.

    Nicotinic–serotonergic interactions in brain and behavior

    Pharmacology, Biochemistry and Behavior

    (2002)
  • W. Sihver et al.

    Development of ligands for in vivo imaging of cerebral nicotinic receptors

    Behavioural Brain Research

    (2000)
  • S. Shoptaw et al.

    Contingency management for tobacco smoking in methadone-maintained opiate addicts

    Addictive Behaviors

    (1996)
  • R. Acierno et al.

    Assault, PTSD, family substance use, and depression as risk factors for cigarette use in youth: Findings from the National Survey of Adolescents

    Journal of Traumatic Stress

    (2000)
  • L.E. Adler et al.

    Normalization of auditory physiology by cigarette smoking in schizophrenic patients

    American Journal of Psychiatry

    (1993)
  • R.F. Anda et al.

    Depression and the dynamics of smoking: A national perspective

    Journal of the American Medical Association

    (1990)
  • R.M. Anthenelli et al.

    Platelet monoamine oxidase activity in subgroups of alcoholics and controls: Results from the collaborative study on the genetics of alcoholism

    Alcoholism, Clinical and Experimental Research

    (1998)
  • J.C. Beckham et al.

    Smoking in Vietnam combat veterans with post-traumatic stress disorder

    Journal of Traumatic Stress

    (1995)
  • H. Berger et al.

    Smoking characteristics of methadone patients

    Journal of the American Medical Association

    (1972)
  • B.L. Borland et al.

    Hyperactive boys and their brothers: A 25-year follow-up study

    Archives of General Psychiatry

    (1976)
  • N. Breslau

    Psychiatric comorbidity of smoking and nicotine dependence

    Behavior Genetics

    (1995)
  • N. Breslau et al.

    Nicotine dependence, major depression and anxiety in young adults

    Archives of General Psychiatry

    (1991)
  • N. Breslau et al.

    Smoking and panic attacks: An epidemiologic investigation

    Archives of General Psychiatry

    (1996)
  • S. Brown et al.

    Causes of the excess mortality of schizophrenia

    British Journal of Psychiatry

    (2000)
  • C.K. Conners et al.

    Nicotine and attention in adult ADHD

    Psychopharmacology Bulletin

    (1996)
  • W.A. Corrigal et al.

    The mesolimbic dopaminergic system is implicated in the reinforcing effects of nicotine

    Psychopharmacology

    (1992)
  • A. Corvin et al.

    Cigarette smoking and psychotic symptoms in bipolar affective disorder

    British Journal of Psychiatry

    (2001)
  • L.S. Covey et al.

    Ever-smoking, quitting and psychiatric disorders: Evidence from the Durham North Carolina, Epidemiological Catchment Area

    Tobacco Control

    (1994)
  • G.W. Dalack et al.

    A clinical approach to help psychiatric patients with smoking cessation

    Psychiatric Quarterly

    (1992)
  • G.W. Dalack et al.

    Nicotine dependence in schizophrenia: Clinical phenomena and laboratory findings

    American Journal of Psychiatry

    (1998)
  • N.C. de Fiebre et al.

    The selectively-bred high alcohol sensitivity (HAS) and low alcohol sensitivity (LAS) rats differ in sensitivity to nicotine

    Alcoholism, Clinical and Experimental Research

    (2002)
  • J. de Leon et al.

    Schizophrenia and smoking: An epidemiological survey in a state hospital

    American Journal of Psychiatry

    (1995)
  • H.D. Desai et al.

    Smoking in patients receiving psychotropic medications: A pharmacokinetic perspective

    CNS Drugs

    (2001)
  • L. Dixon et al.

    The association of medical comorbidity in schizophrenia with poor physical and mental health

    Journal of Nervous and Mental Disease

    (1999)
  • L.C. Dierker et al.

    Smoking and depression: An examination of mechanisms of comorbidity

    American Journal of Psychiatry

    (2002)
  • M.P. Epping-Jordan et al.

    Assessment of nicotinic acetylcholine receptor subunit contributions to nicotine self-administration in mutant mice

    Psychopharmacology (Berl)

    (1999)
  • C.R. Farnam et al.

    Health status risk factors of people with severe and persistent mental illness

    Journal of Psychosocial Nursing and Mental Health Services

    (1999)
  • J. Foulds

    The relationship between tobacco use and mental disorders

    Current Opinion in Psychiatry

    (1999)
  • J.S. Fowler et al.

    Inhibition of MAO B in the brains of smokers

    Nature

    (1996)
  • J.S. Fowler et al.

    Neuropharmacological actions of cigarette smoke: Brain monoamine oxidase B (MAO B) inhibition

    Journal of Addictive Diseases

    (1998)
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