Addressing tobacco among individuals with a mental illness or an addiction
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)
- et al.
Normalization by nicotine of deficient auditory sensory gating in the relatives of schizophrenics
Biological Psychiatry
(1992) - et al.
Panic disorder and cigarette smoking behavior
Comparative Psychiatry
(1999) - et al.
The adolescent outcome of hyperactive children diagnosed by research criteria: I. An 8-year prospective follow-up study
Journal of the American Academy of Child and Adolescent Psychiatry
(1990) - et al.
Prevalence and correlates of heavy smoking in Vietnam veterans with chronic posttraumatic stress disorder
Addictive Behaviors
(1997) - et al.
Self-administered nicotine activates the mesolimbic dopamine system through the ventral tegmental area
Brain Research
(1994) - et al.
Cigarette smoking and neuroleptic-induced parkinsonism
Biological Psychiatry
(1990) - et al.
Neurobiology of schizophrenia
Current Opinion in Neurobiology
(1997) - et al.
Evidence in postmortem brain tissue for decreased numbers of hippocampal nicotinic receptors in schizophrenia
Biological Psychiatry
(1995) - et al.
Smoking and mental illness
Pharmacology, Biochemistry and Behavior
(2001) - et al.
Alpha7 nicotinic receptor mediated protection against ethanol-induced cytotoxicity in PC12 cells
Brain Research
(1999)
Smoking and schizophrenia
Schizophrenia Research
Clozapine decreases smoking in patients with chronic schizophrenia
Biological Psychiatry
Smoking and therapeutic response to clozapine in patients with schizophrenia
Biological Psychiatry
Smoking and movement disorders in psychiatric patients
Biological Psychiatry
Global mortality, disability, and the contribution of risk factors: Global burden of disease study
Lancet
Gating of auditory P50 in schizophrenics: Unique effects of clozapine
Biological Psychiatry
Increased levels of nicotine metabolite cotinine in schizophrenic smokers compared to other smokers
Biological Psychiatry
Smoking in patients with panic disorder
Psychiatry Research
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
An acute dose of nicotine enhances cue-induced cocaine craving
Drug and Alcohol Dependence
Nicotinic–serotonergic interactions in brain and behavior
Pharmacology, Biochemistry and Behavior
Development of ligands for in vivo imaging of cerebral nicotinic receptors
Behavioural Brain Research
Contingency management for tobacco smoking in methadone-maintained opiate addicts
Addictive Behaviors
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
Normalization of auditory physiology by cigarette smoking in schizophrenic patients
American Journal of Psychiatry
Depression and the dynamics of smoking: A national perspective
Journal of the American Medical Association
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
Smoking in Vietnam combat veterans with post-traumatic stress disorder
Journal of Traumatic Stress
Smoking characteristics of methadone patients
Journal of the American Medical Association
Hyperactive boys and their brothers: A 25-year follow-up study
Archives of General Psychiatry
Psychiatric comorbidity of smoking and nicotine dependence
Behavior Genetics
Nicotine dependence, major depression and anxiety in young adults
Archives of General Psychiatry
Smoking and panic attacks: An epidemiologic investigation
Archives of General Psychiatry
Causes of the excess mortality of schizophrenia
British Journal of Psychiatry
Nicotine and attention in adult ADHD
Psychopharmacology Bulletin
The mesolimbic dopaminergic system is implicated in the reinforcing effects of nicotine
Psychopharmacology
Cigarette smoking and psychotic symptoms in bipolar affective disorder
British Journal of Psychiatry
Ever-smoking, quitting and psychiatric disorders: Evidence from the Durham North Carolina, Epidemiological Catchment Area
Tobacco Control
A clinical approach to help psychiatric patients with smoking cessation
Psychiatric Quarterly
Nicotine dependence in schizophrenia: Clinical phenomena and laboratory findings
American Journal of Psychiatry
The selectively-bred high alcohol sensitivity (HAS) and low alcohol sensitivity (LAS) rats differ in sensitivity to nicotine
Alcoholism, Clinical and Experimental Research
Schizophrenia and smoking: An epidemiological survey in a state hospital
American Journal of Psychiatry
Smoking in patients receiving psychotropic medications: A pharmacokinetic perspective
CNS Drugs
The association of medical comorbidity in schizophrenia with poor physical and mental health
Journal of Nervous and Mental Disease
Smoking and depression: An examination of mechanisms of comorbidity
American Journal of Psychiatry
Assessment of nicotinic acetylcholine receptor subunit contributions to nicotine self-administration in mutant mice
Psychopharmacology (Berl)
Health status risk factors of people with severe and persistent mental illness
Journal of Psychosocial Nursing and Mental Health Services
The relationship between tobacco use and mental disorders
Current Opinion in Psychiatry
Inhibition of MAO B in the brains of smokers
Nature
Neuropharmacological actions of cigarette smoke: Brain monoamine oxidase B (MAO B) inhibition
Journal of Addictive Diseases
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