Download Quit Victoria: Safe smoking cessation and mental illness The impact

Quit Victoria: Safe smoking cessation and mental illness
The impact of tobacco use for people with many of the major psychiatric
disorders is a serious health issue. As well, smokers with mental illness who are
trying to quit, have special needs in the area of smoking cessation.
It is clear from the literature that tobacco-smoking rates in people with
schizophrenia, bipolar disorder, personality disorder, anxiety and depression
continue to remain extremely high.i,ii Consumption has been estimated between
two and three times that of the average Australian smoker;iii,iv smoking more, and
often brands with higher tar and nicotine levels.v
On average, smoking is three times more prevalent among people with
schizophrenia, than the general population. Very little research has been done in
Australia but what there is indicates that smoking rates among the mentally ill are
not declining commensurate with the general population. One study conducted at
the Centre for Young People’s Mental Health in Parkville, Victoria, found that
75% of their sample were smokers. Other research conducted in an outpatient
setting in Melbourne reported that 76% of those surveyed were smokers. This
compares to a smoking rate of approximately 20% in the general adult population
in Australia.
A number of studies found that people with schizophrenia report smoking
because it relieves boredom and offers opportunities to socialise when 88% of
them are unemployed and isolated.
Smoking is severely damaging the health of people with mental illness. Deaths
from respiratory and heart disorders are 60% and 30% more likely among people
with mental illness compared to the general population.vi Smoking also has
financial and social implications, especially when there are increasing restrictions
on where people can smoke.
Quitting gives people with a mental illness not only the possibility of a healthier
and longer life, but a better quality of life, freeing finances previously allocated to
tobacco use, for food, accommodation, recreation, and better self-care and
presentation.vii
However there is a complex interaction between tobacco smoking, symptoms of
a mental health condition and some medications used to treat these conditions,
that needs to be considered when supporting safe smoking cessation within this
group.
Smokers with mental health conditions tend to develop a more complicated
dependence than the general community. This is best described as a complex
interaction between nicotine and other components of tobacco, which can affect
the course of psychiatric disorders, the modification of psychoticviii and other
psychiatric symptoms,ix and increase some and reduce other side-effects of
particular medications.x,xi
In addition, because nicotine temporarily increases the activity of brain chemistry,
providing some short-term beneficial effects, some smokers may use cigarettes
to self-medicate symptomsxii or to alleviate the side effects of prescribed
medications,xiii or as some evidence suggests, for an anti-depressant effect.xiv
Therefore any withdrawal of tobacco smoking may be complicated. Various
published guidelines for medical management of cessation in smokers with
mental illness advise close monitoring for effects on psychiatric illness including
depression and anxiety; consideration of pharmacotherapies and other
treatments to assist withdrawal; and the management of medications, their sideeffects and levels, during and following smoking cessation.xv,xvi,xvii,xviii
Smoking can directly impact clinical care by altering medication blood levels.
Smokers require prescription of higher doses of neuroleptics than nonsmokers to
gain a therapeutic effect.xix Accordingly, smoking can interfere with the benefits of
some medications and increase related side effects. At the same time, smoking
can be a means of reducing some side effects, particularly in relation to
antipsychotic drugs. Thus, medication blood levels may be substantially altered
during changes in smoking patterns, and medication dosage may need adjusting
following reduction in smoking.xx
Fluctuations in smoking levels may precipitate or exacerbate psychiatric
symptoms; abrupt cessation may lead to hospitalisation. Withdrawal can be
confused with, or may exacerbate, symptoms of schizophrenia. In Victoria there
are specific guidelines for general practitioners that advise and detail a program
of management and monitoring of quitters with schizophrenia, for the effects of
reduction in smoking on their psychiatric illness and medication.
The link between tobacco use and depression is such that people with a history
of depression are generally described in the literature as more likely to smoke,
more likely to find it difficult to quit and at increased risk of suffering significant
mood disturbance or full blown depression following cessation.xxi,xxii Not every
smoker with a history of major depression, who successfully quits, relapses to
major depression. However, studies report a significantly increased risk of
developing a new episode of major depression, which remains high for at least 6
months following cessation.xxiii,xxiv,xxv Monitoring for depression is advised for at
least 6 months following quitting.
Given the possibility of such interactions, a person’s presentation may vary over
time. Therefore, ongoing face-to-face monitoring of withdrawal by their treating
doctor will provide the best opportunity for people with mental health conditions to
cut down or quit smoking with reduced risk of precipitation or exacerbation of
symptoms or side effects and to ensure any necessary adjustment to prescribed
medication(s).
i
Mental illness and smoking cessation: an urgent public issue. Forum proceedings, 19 November 1996,
compiled by Quit Victoria.
ii
Reichler H, Baker A, Lewin T, & Carr V. Smoking among in-patients with drug-related problems in an
Australian psychiatric hospital. Drug and Alcohol Review 2001;20:231-237.
iii
Wilhelm, K. The relevance of smoking and nicotine to clinical psychiatry, Australian Psychiatry,1998;
6(3):130-132.
iv
Meadows, G, Strasser K, Moeller-Saxone K, Hocking B, Stanton J, & Kee P. Smoking and
schizophrenia: the development of collaborative management guidelines. Australian Psychiatry, 2001;
9(4):340-344.
v
Strasser KM. 2001. Smoking reduction and cessation for people with schizophrenia: Guidelines for
general practitioners. Available online at
www.health.vic.gov.au/mentalhealth/publications/smoke/smoke.pdf (see also …./smoke2.pdf)
vi
Baxter, D.N. (1996). The mortality experience of individuals on the Salford psychiatric register. British
Journal of Psychiatry, 168, 772-229; The SANE Australia Smokefree Kit, 1998, p3.
vii
Polgar S, McGartland M, Borlongan CV, Shytle RD, & Sanberg PR. Smoking cessation programmes are
neglecting the needs of persons with neuropsychiatric disorders. Aust NZ Journal of Medicine, 1996;26,
572.
viii
Strasser, K., Moeller-Saxone, K., Meadows, G., Hocking, B., Stanton, J., and Kee,P. Smoking cessation
in schizophrenia: General practice guidelines. Australian Family Physician, 2002; 31(1), 21-24.
ix
Glassman, A.H. Cigarette smoking: Implications for psychiatric illness. American Journal of Psychiatry,
1993; 150:546-553.
x
Goff DC, Henderson DC, Amico E. Cigarette smoking in schizophrenia: relationship to psychopathology
and medication side effects. American Journal of Psychiatry; 1992; 149: 1189-1194.
xi
Lyon ER. A review of the effects of nicotine on schizophrenia and antipsychotic medications.
Psychiatric Serv 1999;50(10):1346-50.
xii
Dalack GW, Healy MD, & Meador-Woodruf JH. Nicotine dependence in schizophrenia: Clinical
phenomena and laboratory findings. American Journal of Psychiatry; 1998; 155:1490-1501.
xiii
Adler, L.E., Hoffer, L.D., Wiser, A., & Freedman, R. Normalisation of auditory physiology by cigarette
smoking in schizophrenic patients. American Journal of Psychiatry 1993; 150(12), 1856-1861.
xiv
Foulds J. (1999). The relationship between tobacco use and mental disorders. Substance misuse:
Current opinion in Psychiatry 1999, 12:303-306.
xv
Fiore, M C et al. Clinical Guideline: Treating tobacco use and dependence. U.S. Department of Health
and Human Services. June 2000.
xvi
American Psychiatric Association. Practice guidelines for the treatment of patients with nicotine
dependence. American Journal of Psychiatry, 153:10, October 1996 Supplement. Available online at
www.psych.org
xvii
Miller M, & Wood, L. National Tobacco Strategy 1999 to 2002-03 Occasional Paper. Smoking
cessation interventions: Review of evidence and implications for best practice in health care settings.
August 2001. Commonwealth of Australia, 2002. Available online at
http://www.health.gov.au/pubhlth/publicat/document/smoking_ces.pdf
xviii
NSWhealth. Guide for the Management of Nicotine Dependent Inpatients. Available on line at
www.health.nsw.gov.au/public-health/health-ptomotion/pdf/Tobacco/patsmoke.htm
xix
Hughes JR, Hatsukami DK, Mitchell JE, & Dahlgren LA. Prevalence of smoking among psychiatric
outpatients. American Journal of Psychiatry; 1986; 143, 993-997.
xx
Maguire, T. Smoking and medicines fact sheet, Pharmacists’ action on smoking: smoking cessation for
a healthier nation. Leaflet.CMC.PJH.6.94
xxi
Glassman, A.H. Cigarette smoking: Implications for psychiatric illness. American Journal of
Psychiatry, 1993; 150:5446-553.
xxii
Covey LS. Tobacco cessation among patients with depression. Prim Care 1999;26(3):691-706.
xxiii
Miller M, & Wood, L. National Tobacco Strategy 1999 to 2002-03 Occasional Paper. Smoking
cessation interventions: Review of evidence and implications for best practice in health care settings.
August 2001. Commonwealth of Australia, 2002.
xxiv
Glassman AH, Covey LS, Stetner F, & Rivelli S. Smoking cessation and the course of major
depression: a follow-up study. The Lancet,2001; 357:1929-1932.
xxv
Glassman AH, & Covey LS. Smoking and affective disorder. Am J of Health behavior 1996; 20(5):
279-285.