5/3/2012
Providing Tobacco Cessation for
People with Mental Illness
Jamie L. Pomeranz, Ph.D.
University of Florida
Department of Behavioral Science and Community Health
October 20, 2011
Acknowledgement
Personal Background
• Certified Rehabilitation Counselor
• Ph.D. in Rehabilitation Science
• 20 years working with people with disabilities.
• Core Faculty with ATTAC–IT representing the
College of Public Health and Health Professions
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5/3/2012
Presentation Outline
• Overview
• Schizophrenia
p
• Bipolar
Disorder
• Depression
• Anxiety
About 443,000 U.S. Deaths Attributable Each Year
to Cigarette Smoking
Source MMWR, 2008
Ischemic Heart
Disease,
126,000
Lung Cancer,
128,900
Other Cancers,
35,300
Chronic
Obstructive
Pulmonary
Disease, 92,900
Other
Diagnoses,
44,000
Stroke, 15,900
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Economic Costs Associated with Cigarette
Smoking
193 Billion Dollars Annualy
Loss of
Productivity
49%
Direct Medical
Costs
51%
Annual Avoidable Deaths
0
100
200
300
400
500,000
AIDS
Alcohol
Motor Vehicle
Fires
Homicide
Illicit Drugs
Suicide
Smoking
443,000 Annual Deaths
1215 Per Day
Equivalent to three 747 jets crashing each day
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5 Million Annual Deaths Worldwide
14,000 deaths each day worldwide
Equivalent to 30 747 jets crashing each day
Florida Fatalities
• Average deaths per 10 years
– Shark attacks (2-3)
– Alligator attacks – (3-10)
– Lightening strikes – (90)
– Murders – (10,000)
–Tobacco Use (300,000)
Overview
• Individuals with mental illness smoke nearly
half of all the cigarettes in the United states
(Lasser et al., 2000).
• Tobacco dependence has been overlooked by
behavioral health specialists treating
individuals with mental health conditions
(Williams and Hughes, 2003).
• Individuals with severe mental illness die 25
years earlier than the general population
primarily due to smoking (NASMHPD, 2007).
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5/3/2012
Overview
• In exhaustive literature reveals smoking research
primarily on schizophrenia, depression, bipolar
disorder and anxiety.
y
Issues to Discuss
• Research on Treatment
• Treatment Considerations
• Barriers to Quitting
Schizophrenia
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Percentage of Individuals with Schizophrenia
who Smoke
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
88%
24%
Smoking General Population
Schizophrenia
Series 1
Schizophrenia
• 2 million people living in the US with schizophrenia.
• Mental disorder characterized by a disintegration of
thought processes and of emotional responsiveness.
• To be diagnosed, people experience 2 or more of the
following symptoms:
– Delusions (often bizarre or persecutory in nature)
– Hallucinations (most reported as hearing voices)
– Disorganized Speech
– Grossly Disorganized or Catatonic Behavior
– Negative Symptoms (flat affect, in ability to
experience pleasure, etc.)
Research on Treatment
• According to the literature, approximately 88% of
individuals with schizophrenia smoke (Dalack et al., 1996).
• Over three times higher than the general population.
– 10 times more likely to have ever smoked daily
– Altered cigarette puffing (greater nicotine intake)
– Less likely to quit (50% compared to the other groups receiving
treatment)
– More likely to smoke compared to other mental illnesses (Steinberg
& Williams, 2007).
• Due to the increase in metabolism of certain medications,
individuals with schizophrenia who smoke are prescribed
higher doses of antipsychotic medications.
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Research on Treatment
• Due to limited financial resources, individuals with
schizophrenia often spend close to 27% of their monthly
public assistance benefits on cigarettes (Steinberg et al., 2004).
• Research suggests that smoking alleviates attention and
concentration
by
t ti problems
bl
b filtering
filt i outt distracting
di t ti noises
i
(Adler et al., 1998).
• Case reports by Dalack and colleagues 1996 suggesting
nicotine withdrawal leads to an exacerbation of
schizophrenic symptoms.
Treatment Considerations
• Nasal Spray correlated with better outcomes and low
discontinuation rates (rapid nicotine delivery) (Williams &
Foulds, 2007).
• Clozapine treatment associated with reduced
smoking
g (increases
(
acetocholene release, activatingg
nicotinic receptors, thus reducing the desire to
smoke) (Williams & Foulds, 2007).
• Smoking increases the clearance of antipsychotic
medications, requiring higher antipsychotic doses
(Dalack et al., 1999).
Treatment Considerations
• Tobacco smoke increases caffeine metabolism
by 60-70% (Zevin and Benowitz, 1999).
– Caffeine effects can produce similar effects as seen
with nicotine withdrawal.
– Heavy use of caffeine by individuals with
schizophrenia.
– Caffeine confounds tests of cognitive function in
acutely abstinent smokers with schizophrenia (Williams
and Gandhi, 2008).
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Treatment Considerations
• Tolerating reduced smoking (as opposed to setting a
specific quit date).
• Group or individual treatment appropriate for this
population.
• Longer and more intense treatment
• Treatment should not focus on pharmacological
therapy alone.
• Consider cognitive issues.
• Contingent Reinforcement.
Treatment Barriers
• Increased severity of nicotine dependence.
• Reduced access to treatment due to clients being
unorganized or unmotivated to quit.
• Adherence to the nicotine patch was found to be
diffi l to maintain.
difficulty
i i
• Longer to achieve cessation.
• Overcome barriers by using motivational
interviewing and personalized feedback (Steinberg et al.,
2004).
Bipolar Disorder
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Bipolar Disorder
• Bipolar disorder, also known as manic-depressive illness,
is a brain disorder that causes unusual shifts in mood,
energy, activity levels, and the ability to carry out day-today tasks.
• People with bipolar disorder experience unusually intense
emotional states that occur in distinct periods called
"mood episodes." An overly joyful or overexcited state is
called a manic episode, and an extremely sad or hopeless
state is called a depressive episode.
Research on Treatment
• Bipolar patients have markedly elevated rates of
nicotine dependence (Gonzalez et al., 1998; Grant et al., 2004).
– Compared to 12.8% in the general population,
35.3% of those with bipolar I disorder and 33.4%
of those with bipolar II disorder met criteria for
nicotine dependence in the past 12 months.
Research on Treatment
• Approximately 46.4% of persons with bipolar
disorder were current smokers, and 15.1% of these
individuals were heavy smokers. (NHIS, 2007).
• Rates of smoking among people with bipolar
di d range from
disorder
f
43% to
t 82% (Grant et al., 2004; Lasser et al.,
2000; John et al., 2004; Itkin et al., 2001).
• The presence of mania and hypomania was
associated with 3.9 and 3.5 times greater likelihood
of tobacco dependence (Grant et al., 2004).
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Treatment Considerations
• Beyond the adverse health implications of
smoking, people with bipolar disorder who
smoke are at higher risk of suicidal behavior and
suicide attempts (Ostacher et al., 2009).
– Some have suggested that an aggression/impulsivity
factor may predispose certain individuals with bipolar
disorder to suicidal behavior, substance abuse
disorders, and smoking (Oquendo et al., 2004; Grunebaum et al., 2006;
Dumais et al., 2005).
Treatment Considerations
• Studies have demonstrated that nicotine
withdrawal is linked to increased mania,
depression and irritability (Glassman, 1993), suggesting
g an ameliorative
that nicotine mayy be pproviding
effect on bipolar symptoms.
Treatment Barriers
• Emergence of depression after abrupt smoking
cessation (Labbate, 1992).
• Emergence of mania after abrupt smoking
cessation (Labbate, 1992; Benazzi, 1989).
• Emergence of mania during varenicline treatment
(Kohen & Kremen, 2007).
• Emergence of mania after bupropion
discontinuation (Michael, 2004).
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Depression
Depression
• Depression is a medical disorder characterized by
feelings of sadness, hopelessness, pessimism, guilt,
and a general loss of interest in life, combined with
a sense of reduced emotional well-being and low
energy
energy.
• People with depression also tend to have disturbed
sleep, reduced appetite and may even feel suicidal.
Research on Treatment
• Depression increases the risk of smoking (Murphy et al., 2003).
• Depressive symptoms are associated with poor smoking
cessation outcomes (Macpherson et al., 2010).
• Antidepressant medications largely have not impacted
depressive symptoms during quit attempts (Kahler et al., 2002).
• Those with depressive symptoms tend to smoke to
improve their mood (McClernon et al., 2006; Shytle et al., 2002).
• Smokers who successfully quit as compared to smokers
who were unsuccessful have not exhibited an increase in
depression, and anxiety or suicide ideation (Berlin, 2010)
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5/3/2012
Research on Treatment
• Menstrual discomfort and smoking withdrawal
sympotomatology greater for women with a history of
depression during smoking abstinence (Pomerleau, 2000).
Research on Treatment
• Mixed reports of Chantix for individuals with a
history of depression.
• Varenicline not been widely tested in patients
with mental illness (Raidoo & Kutscher, 2009).
Treatment Considerations
• Consider menstrual phase for women with a
history of depression.
• Awareness of the exacerbation of mental illness
and causation of depressive
p
symptoms
y p
(Raidoo &
Kutscher, 2009).
• Longer treatments and follow-up.
• Behavioral activation strategies (MacPherson 2010).
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Treatment Barriers
• Fear of helplessness.
• Menstrual discomfort.
• Motivation to quit.
• Mixed studies on the effects of Varenicline.
• Fear of not being successful, leading to
increased depressive symptoms.
Anxiety
Anxiety
• People with anxiety disorders feel extremely fearful
and unsure.
• Most people feel anxious about something for a
short period of time now and again
again, but people with
anxiety disorders feel this way most of the time.
• About 18% of American adults have anxiety
disorders.
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Research on Treatment
• Limited research on the relationship of anxiety to
smoking.
• 60 million smokers in the US have had at least one anxiety
disorder in their life-time ( Piper et al., 2010).
• Smokers with anxiety disorders report higher levels of
nicotine dependence, pre-quit withdrawal symptoms, and
less likely to remain abstinent 8 weeks after quitting (Piper et
al., 2010).
• Smokers with panic disorder have a greater motivation to
smoke in order to reduce negative affects (Zvolensky et al., 2004).
Research on Treatment
• Reduced coping resources leading to more cessation
fatigue and resilience to deal with the challenge of
quitting (Piper et al., 2010).
di id l with
ith a history
hi t
i disorder
di d reportt less
l
• IIndividuals
off panic
confidence in remaining abstinent from smoking during
emotional distress (Zvolensky, 2004).
Treatment Considerations
• More intensive individual or group counseling
early in the treatment process.
• Place emphasis on coping skills and navigating
environmental cues.
• Address negative affect associated with the
“quit day.”
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Treatment Barriers
• Cessation fatigue higher for individuals with a
history of anxiety.
• History of panic attacks correlated with inability
to establish initial cessation.
• Smoking serves as a coping strategy.
• Lower levels of long-term abstinence associated
with anxiety disorders.
Conclusion
• Many within the field of mental health believe it
is inadvisable to address tobacco cessation for
individuals with psychiatric conditions.
• Accordingg to the literature,, tobacco use can be
successfully treated within this population.
• Lack of tobacco treatment delays the necessary
treatment for mental disorders, increasing the risk
of negative health consequences (Dwyer, 2008).
Thank You
pomeranz@phhp.ufl.edu
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