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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.