Tobacco Update: Scientific Advances, Clinical Perspectives
Serious Mental Illness and Tobacco Addiction: A Model Program to Address This Common but Neglected Issue

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ABSTRACT

Tobacco addiction among persons with serious mental illness (SMI) has been largely ignored. About 75 to 85% of persons with schizophrenia, bipolar disorder, and other SMI use tobacco; most will either die and/or have reduced quality of life because of tobacco-caused medical diseases. Tobacco addiction is the most common co-occurring disorder for the SMI population. A dramatic reduction in tobacco use in the general population has occurred during the past 40 years; however, there has been almost no reduction for smokers with SMI. The University of Medicine and Dentistry of New Jersey program targets smokers with SMI and provides outreach services, clinical treatment and research, and consultation to other community-based mental health treatment agencies in New Jersey. Clinical and research evidence supports motivation-based treatment, blending mental health and addiction treatment approaches, and integrating tobacco dependence treatment within mental health settings. The unique barriers and clinical issues for this population are described.

Section snippets

The Impact of Smoking

The primary concern with tobacco use is that it causes considerable morbidity and mortality in all smokers.6., 7., 8. The rates of cancer and cardiovascular and respiratory diseases among persons with SMI are double those of age-matched control subjects because of the 2- to 3-fold increased rate of tobacco addiction.9., 10. In addition to increased medical comorbidity, smokers with SMI experience increased psychiatric symptoms, hospitalizations, and need for higher medication doses compared

Effects on Medications

The liver cytochrome P450 enzymes metabolize tobacco as well as many psychiatric medications, including commonly used antipsychotic, antianxiety, and antidepressant medications.12 Tobacco (not nicotine) induces the CYP1A2 isoenzyme, resulting in increased metabolism and thus an increased clearance rate of these medications. Smokers often require about double the medication dosage (for CYP1A2-metabolized medications) compared with nonsmokers, often leading to increased side effects and costs.

Factors Increasing Tobacco Dependence among Persons with SMI

There is no simple explanation for the prevalence of smoking among persons with SMI. It is most likely that biological, psychological, and social risk factors contribute to the phenomenon, including neurobiological vulnerability, increased severity of withdrawal symptoms, poor coping skills, and self-medication for attention, mood, and anxiety symptoms. Furthermore, the social reinforcements to smoke in mental health and addiction treatment settings are contributory.14., 15.

As with other

Tobacco Control and Mental Health System Changes

To improve the manner in which we address tobacco use, one option is to use the co-occurring mental illness and addiction paradigm. Available evidence supports the use of an integrated treatment to produce the best outcomes. Within the existing mental health team approach, we developed a model in which psychiatric and nicotine dependence treatment medications are prescribed by the team psychiatrist (or advance practice nurse), addressing tobacco becomes part of the agenda in current mental

Program Development and Consultation

The UMDNJ Tobacco Dependence Program, under the leadership of Drs. Ziedonis, Foulds, and Williams, has developed an effective model for treating tobacco in persons with SMI and a model for instituting changes to better address tobacco in other mental health settings. Dr. John Slade had originally founded this program to address tobacco in addiction treatment settings, and the model has been adapted for the special issues within mental health settings. The UMDNJ Program is described on its web

The UMDNJ Nicotine Craving Laboratory

The cue exposure paradigm offers a unique method to systematically prime patients with drug cues40 and to test out the efficacy of anticraving medications.41 At the Veterans Administration New Jersey Health Care System and Robert Wood Johnson Medical School, we have developed a cocaine craving laboratory and are now expanding this initiative into a nicotine craving laboratory. A large body of research has accumulated over the years to suggest that cue exposure is a reliable method for studying

A National Plan to Address Tobacco in Mental Health Settings

There is a great need for a national strategic plan to address tobacco dependence among persons with SMI. The SAMHSA Report to Congress on Co-occurring Addiction and Mental Illness49 includes tobacco and mental illness as a subtype of co-occurring disorder. During the same period (November 2002 through June 2003), a series of meetings on addressing tobacco among persons with mental illness and addictions occurred that, for the first time, brought together researchers, clinicians,

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    This work was supported in part by Center for Substance Abuse Treatment grant DK1-TI12549-01 (to dmz), National Institute on Drug Abuse grants R01-DA15978-01 and R01-DA015537 (to dmz) and K-DA14009-01 (to jmw). dmz and jmw are also supported in part by the New Jersey Department of Health and Senior Services through the Comprehensive Tobacco Control Program and the Robert Wood Johnson Foundation.

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