SMOKING
CESSATION FOR
PEOPLE WITH
MENTAL ILLNESS
A Guide for Health Practioners
Providing ABC
This document summarises the evidence regarding smoking cessation for
people with mental illness.
Smoking Cessation for People with Mental Illness
Smoking Cessation for People with
Mental Illness
A GUIDE FOR HEALTH PRACTIONERS PROVIDING ABC
INTRODUCTION
People with mental illness are more likely to smoke than those without mental illness (1). For decades, smoking has
been part of the ‘culture’ of mental health institutions with cigarettes being used as rewards for good behaviour and
as a coping mechanism.
Despite their higher rates of smoking, encouraging people with mental illness to stop smoking is often overlooked by
healthcare professionals (2). Yet, like the general population many of these people want to quit smoking, for reasons
such as cost and health, and many try each year. Most will try unaided where their chances of quitting long-term are
low (3).
Are people with mental illness less likely to quit smoking than those without
mental illness?
There are differences in demographics and smoking history that exist between smokers in the general population and
those with mental illness that contribute to lower quit rates. For example, people with mental illness who smoke,
typically show higher levels of tobacco dependence (1, 4). People with a history of mental illness may be more likely
to experience depressed mood when quitting and depressed mood has been found to predict relapse to smoking (5).
Of course low mood is a well-documented tobacco withdrawal symptom and major depression has been reported
during smoking abstinence (6).
However, people with mental illness can achieve similar quit rates to smokers from the general population. Results
from a longitudinal study in primary care showed that people with mental illness were just as likely to receive smoking
cessation counselling and be successful in quitting as those smokers without mental illness (7). Similar results have been
observed within specialist smoking cessation treatment programmes (8).
Effects of stopping smoking on mental health
Although there are reports of people with mental illness reporting deterioration in mental health on stopping smoking,
there are also data to the contrary. In fact there is good evidence that among patients with schizophrenia or
schizoaffective disorder, those who manage to stop smoking do not experience any worsening in their condition (9,
10). There are also data showing that mood improves in depressed smokers, who manage to stop smoking, compared
to those who fail in their quit attempt (11, 12).
Page 1
Smoking Cessation for People with Mental Illness
Overall, there is good evidence that receiving smoking cessation interventions does not adversely affect mental health
(13, 14).
SMOKING CESSATION TREATMENT OPTIONS
The best outcomes are generally seen with a combination of behavioural support and pharmacotherapy (15). The
New Zealand Smoking Cessation Guidelines recommend that people with mental illness who smoke be offered the
same treatment options as those people without mental illness (16).
Use of pharmacotherapies in people with mental illness
The majority of data regarding pharmacotherapy for smoking cessation are from studies where people with mental
illness were excluded from participating, which limits the generalizability of these results. However, there have been
a small number of studies examining the efficacy of smoking cessation medications in people with mental illness that
suggest that these are likely to be as efficacious as seen in this population (17, 18). There are limited data regarding
the efficacy of NRT use in people with mental illness. However, the available data suggests that NRT can be used
with good effect in this population and that NRT does not have any adverse effect on psychiatric symptoms.
Bupropion appears to be effective in aiding smoking cessation in people with schizophrenia. Tsoi et al (2010) pooled
the results of five RCTs and showed a significant effect of bupropion, compared to placebo, on abstinence at 6months (Risk Ratio=2.78, 95%CI: 1.02-7.58) (18). Although bupropion was well tolerated in these studies, clinicians
need to be aware of the increased risk of seizure when combining it with other medications that lower seizure
threshold and monitor people with mental illness for change in mental symptoms.
Current data suggests that varenicline may also be helpful in aiding smoking cessation in people with mental illness.
Data also suggest that adverse effects are similar as to those seen in the general population (19, 20). However, none
of the studies to date can exclude an increased risk of psychiatric adverse events and more data are needed from
larger RCTs. Varenicline can be considered for use in people with mental illness, but use with caution and care taken
to ensure that these people receive regular follow-up. Regular follow-up is part of safe practice, and also best
practice for smoking cessation support.
Effect of stopping smoking psychiatri c mediations
Smoking and stopping smoking have an effect on the metabolism of a number of drugs used in the management of
mental illness.
Tobacco smoke contains substances, such as polycyclic aromatic hydrocarbons (PAHs) that give rise to increased
expression of cytochrome P450 (CYP450) enzymes, found in the liver and other tissues. There are many other factors
that affect CYP450 activity (e.g. age, genetics, other medicine) and so smoking status alone does not fully predict
changes in drug metabolism. However, changes in smoking status need to be considered with certain drugs.
The evidence regarding changes in the metabolism of psychiatric medications following smoking cessation is strongest
for clozapine and olanzapine. People on these drugs who stop smoking should have their drug levels monitored and
their doses lowered. There is data to show that smokers have lower plasma levels of perphenazine, fluphenazine,
thioridazine, duloxetine, fluvoxamine, clomipramine and imipramine than non-smokers. However, it is not clear if
Page 2
Smoking Cessation for People with Mental Illness
dosage adjustments are required following smoking cessation. The data regarding the effects of smoking on
amitriptyline, nortriptyline, and haloperidol are mixed (21, 22).
PRACTICE POINTS
ABC for smoking cessation
The ABC approach for smoking cessation reminds clinicians of three key steps to providing better help for smokers to
quit.
A. Asking if people smoke (or screening for tobacco use)
B. Giving brief advice to quit to all identified smokers every time they present at General Practice, and then
C. Offering cessation support. The most effective treatment combines pharmacotherapy with behavioural
support. People with mental illness can be referred to local stop smoking services such as Aukati Kai Paipa
(smoking cessation service for Maori) and others run by DHBs and PHOs. Some areas also have access to
Pacific smoking cessation services. The Quitline (0800 778 778) also provides multisession behavioural
support delivered via telephone. NRT (patch, gum and lozenge), bupropion, nortriptyline and varenicline are
available and subsidized. Help to quit is also available online www.quit.org.nz.
For people on psychiatric medications that are affected by tobacco smoke (e.g. clozapine), mechanisms should be in
place to check plasma drug levels, and adjust the dose where necessary, following smoking cessation. Some experts
have recommended the dose of clozapine and olanzapine needs to be reduced by approximately 35% when people
stop smoking (23). A reduction in cigarette consumption does not require dosage adjustment.
Page 3
Smoking Cessation for People with Mental Illness
Notes on medication use
NICOTINE REPLACEMENT THERAPY
NRT is easy to use, can be started with immediate effect, and has no drug interactions. For a quick reference guide
to NRT dose copy and paste this link into your web browser: www.quit.org.nz/file/quitcards/nrt-assessment-august2012-online.pdf
NRT can also be used to assist people to refrain from smoking when they are in smokefree environments. Most DHBs
have guidance for staff on the management of nicotine withdrawal.
NRT is available on prescription or via QuitCards. Healthcare professionals, who do not prescribe, can register as a
QuitCard provider after completing the online smoking cessation
e-learning tool. www.smokingcessationabc.org.nz
PRESCRIPTION ONLY MEDICINES
Nortriptyline, bupropion, and varenicline are prescription only medicines. Some advice relevant to their use in people
with mental illness is summarized below. For full prescribing information please consult the product datasheets
available on the MedSafe website.

Zyban must not be used in patients with predisposing risk factors for seizures unless there is a compelling clinical
justification for which the potential medical benefit of smoking cessation outweighs the potential increased risk of
seizure (24). In these patients, a maximum dose of 150mg should be considered for the duration of treatment.
Predisposing risk factors for seizures include: use of medicines known to lower the seizure threshold (e.g.
antipsychotics, antidepressants, antimalarials, tramadol, theophylline, systemic steroids, quinolones and sedating
antihistamines); excessive use of alcohol or sedatives; history of head trauma; diabetes treated with
hypoglycaemics or insulin; use of stimulants or anorectic products.

Depression, rarely including suicidal ideation, has been reported in patients undergoing a smoking cessation
attempt, including during early stages of treatment. Patients should be advised accordingly.
 For the full prescribing information on Zyban, please see the New Zealand data sheet, available at:
www.medsafe.govt.nz/profs/Datasheet/z/zybantab.pdf

Varenicline should be used with caution in people with mental illness (25). People with mental illness may
experience worsening of their pre-existing psychiatric illness while taking varenicline and should be monitored
closely.

There have also been reports of depression and suicidal ideation in people using varenicline. Although there is no
firm evidence of causality, caution is warranted. The datasheet advises "Patients and their families should be
advised that the patients should stop taking CHAMPIX and contact a health care professional immediately if changes
in behaviour, agitation or depressed mood, that are not typical for the patients are observed, or if the patient
develops suicidal ideation or suicidal behaviour" (26).

Risks and benefits: It is important to discuss the possibility of serious neuropsychiatric symptoms in the context of
the benefits of quitting smoking with patients.
 For the full prescribing information on varenicline, please see the New Zealand data sheet, available
at: www.medsafe.govt.nz/profs/Datasheet/c/Champixtab.pdf
Page 4
Smoking Cessation for People with Mental Illness
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
DE LEON, J.
& DIAZ, F. J. (2005) A meta-analysis of worldwide studies demonstrates an association between schizophrenia and
tobacco smoking behaviors, Schizophrenia Research, 76, 135-57.
STRASSER, K. M. (2001) Smoking reduction and cessation for people with schizophrenia. Guidelines for general practitioners
(Melbourne, SANE Australia & University of Melbourne).
HUGHES, J. R., GULLIVER, S. B., FENWICK, J. W. et al. (1992) Smoking cessation among self-quitters, Health Psychology, 11, 331-4.
HAUG, N. A., HALL, S. M., PROCHASKA, J. J. et al. (2005) Acceptance of nicotine dependence treatment among currently
depressed smokers, Nicotine & Tobacco Research, 7, 217-24.
SWAN, G. E., WARD, M. M. & JACK, L. M. (1996) Abstinence effects as predictors of 28-day relapse in smokers, Addict Behav,
21, 481-90.
COVEY, L. S., BOMBACK, A. & YAN, G. W. Y. (2006) History of depression and smoking cessation: A rejoinder, Nicotine & Tobacco
Research, 8, 315-319.
ONG, M. K., ZHOU, Q. & SUNG, H. Y. (2011) Primary care providers advising smokers to quit: comparing effectiveness between
those with and without alcohol, drug, or mental disorders, Nicotine & tobacco research : official journal of the Society for
Research on Nicotine and Tobacco, 13, 1193-201.
STAPLETON, J. A., WATSON, L., SPIRLING, L. I. et al. (2008) Varenicline in the routine treatment of tobacco dependence: a pre-post
comparison with nicotine replacement therapy and an evaluation in those with mental illness, Addiction, 103, 146-54.
EVINS, A. E., CATHER, C., CULHANE, M. A. et al. (2007) A 12-week double-blind, placebo-controlled study of bupropion SR
added to high-dose dual nicotine replacement therapy for smoking cessation or reduction in schizophrenia, Journal of Clinical
Psychopharmacology, 27, 380-386.
WILLIAMS, J. M., STEINBERG, M. L., ZIMMERMANN, M. H. et al. (2010) Comparison of two intensities of tobacco dependence
counseling in schizophrenia and schizoaffective disorder, Journal of Substance Abuse Treatment, 38, 384-393.
BLALOCK, J. A., ROBINSON, J. D., WETTER, D. W., SCHREINDORFER, L. S. & CINCIRIPINI, P. M. (2008) Nicotine Withdrawal in Smokers
With Current Depressive Disorders Undergoing Intensive Smoking Cessation Treatment, Psychology of Addictive Behaviors, 22,
122-128.
THORSTEINSSON, H. S., GILLIN, J. C., PATTEN, C. A. et al. (2001) The effects of transdermal nicotine therapy for smoking cessation
on depressive symptoms in patients with major depression, Neuropsychopharmacology, 24, 350-8.
ALLEN, M. H., DEBANNE, M., LAZIGNAC, C. et al. (2011) Effect of nicotine replacement therapy on agitation in smokers with
schizophrenia: a double-blind, randomized, placebo-controlled study, American Journal of Psychiatry, 168, 395-399.
BAKER, A., RICHMOND, R., HAILE, M. et al. (2006) A randomized controlled trial of a smoking cessation intervention among people
with a psychotic disorder, Am J Psychiatry, 163, 1934-42.
MCROBBIE, H., BULLEN, C., GLOVER, M. et al. (2008) New Zealand smoking cessation guidelines, New Zealand Medical Journal,
121, 57-70.
MINISTRY OF HEALTH (2007) New Zealand Smoking Cessation Guidelines (Wellington, Ministry of Health).
BANHAM, L. & GILBODY, S. (2010) Smoking cessation in severe mental illness: what works?, Addiction, 105, 1176-1189.
TSOI, D. T., PORWAL, M. & WEBSTER, A. C. (2010) Interventions for smoking cessation and reduction in individuals with
schizophrenia, Cochrane Database of Systematic Reviews.
MCCLURE, J. B., SWAN, G. E., CATZ, S. L. et al. (2010) Smoking outcome by psychiatric history after behavioral and varenicline
treatment, Journal of Substance Abuse Treatment, 38, 394-402.
WILLIAMS, J. M., ANTHENELLI, R. M., MORRIS, C. D. et al. (2012) A randomized, double-blind, placebo-controlled study evaluating
the safety and efficacy of varenicline for smoking cessation in patients with schizophrenia or schizoaffective disorder, The
Journal of clinical psychiatry, 73, 654-60.
ZEVIN, S. & BENOWITZ, N. L. (1999) Drug interactions with tobacco smoking - An update, Clinical Pharmacokinetics, 36, 425-438.
DESAI, H. D., SEABOLT, J. & JANN, M. W. (2001) Smoking in patients receiving psychotropic medications - A pharmacokinetic
perspective, Cns Drugs, 15, 469-494.
WENZEL-SEIFERT, K., KOESTLBACHER, A. & HAEN, E. (2011) Dose-dependent effects of cigarette smoking on serum concentrations of
psychotropic drugs, Therapeutic Drug Monitoring, 33, 481-482.
GLAXOSMITHKLINE NEW ZEALAND LTD (2012) ZYBAN: New Zealand Datasheet.
PURVIS, T. L., NELSON, L. A. & MAMBOURG, S. E. (2010) Varenicline use in patients with mental illness: an update of the evidence,
Expert Opin Drug Saf, 9, 471-82.
PFIZER NEW ZEALAND LTD (2012) Champix: New Zealand Datasheet.
Page 5