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A. Overview

Smoking is common among individuals with other substance use and psychiatric disorders (698, 699). Although most psychiatrists do not offer comprehensive nicotine dependence treatment, the multiple negative health effects of tobacco use make it important for clinicians to identify tobacco smokers and smokeless tobacco users, provide motivational interventions to encourage patients to quit tobacco use, and be familiar with medications and psychosocial interventions that are effective in treating nicotine dependence. Although there have been several recent controlled studies of smoking cessation treatments among psychiatric patients (414, 700–705), most of these studies have been of limited sample size and primarily involved cohorts of patients with schizophrenia. Thus, much of what is recommended in this section is similar to other recommendations for psychiatric patients who smoke (173, 414, 698, 705) as well as being consistent with guidelines from the U.S. Public Health Service (706) for the treatment of smokers who do not have a current psychiatric disorder. It is also important to note that the treatment of nicotine dependence differs from that of other drug dependencies in the following ways: 1) treatment commonly uses pharmacotherapies (e.g., NRT, bupropion), with varying levels of behavioral treatment given to those willing to receive it; 2) a specific "quit date" when all tobacco use is to cease is set; 3) a nicotine-dependent individual generally does not experience substantial social/occupational dysfunction due to tobacco use; 4) there is less of a need for family involvement in such treatment; and 5) effective over-the-counter medication treatments are available for treating this dependence.

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B. Assessment

In addition to the general aspects of assessment outlined in Section II.B, the patient's current level of tobacco use (e.g., number of cigarettes per day) and degree of nicotine dependence also need to be determined, because highly nicotine-dependent individuals are more likely to need more intensive therapy, especially pharmacotherapy. The Fagerström Test for Nicotine Dependence (Table 4) is widely used in treatment studies and has proven reliability and validity (707–710).

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Table Reference Number
Table 4. Fagerström Test for Nicotine Dependence

A score of <3 on this scale indicates that an individual has very low or no nicotine dependence, whereas a score of 6 suggests that an individual is highly dependent on nicotine (708). This scale can also predict which smokers are likely to quit smoking and which may benefit from high-dose NRT (described in Section III.E.1). Nicotine dependence in smokeless tobacco users is common, and attempts have been made to measure dependence levels in this group as well (712).

Several other markers of nicotine dependence have been proposed, such as number of cigarettes per day, time to first cigarette (an item on the Fagerström test), cotinine levels, degree of withdrawal on last attempt, and number of unsuccessful attempts to quit. However, with the possible exception of time to first cigarette (713), these markers have yet to be shown to have significant treatment utility. DSM criteria for substance dependence (Table 2) also appear to be reliable and have prospective validity in diagnosing nicotine dependence (714).

As indicators of use, nicotine and cotinine levels can be measured in blood, saliva, and urine (105). Nicotine levels can reflect tobacco use over the last few hours, whereas the level of cotinine, a metabolite of nicotine, is sensitive to tobacco use in the last 7 days and offers a better measure of total daily nicotine exposure (105). It has been proposed that the measurement of cotinine levels be used to help guide nicotine replacement, but the utility of this strategy has not been well tested (173). An individual's carbon monoxide level is usually measured by breath and reflects smoking only over the last few hours (105). It has been suggested that the measurement of carbon monoxide is a means of motivating a patient to cease tobacco use or reinforcing abstinence (715), but the efficacy of this is unclear. The major benefit to using carbon monoxide levels as a marker is that it is easily measured and can be used to verify cessation of tobacco use when patients are using an NRT (105). Because smokers in nontreatment (or minimal treatment) settings are usually truthful about their smoking status and the number of cigarettes smoked per day (716), the described measures are not necessary for evaluating smoking cessation, although they show promise as helpful assessments.

Because 70% of smokers make more than one attempt to stop smoking (602), it is important and useful to inquire about and assess patient perceptions about prior attempts and past treatment adequacy. In addition to determining the patient's reasons for previous attempts to quit tobacco use and the amount of time he or she remained abstinent, it is important to assess the perceived cause of relapse. For example, was the relapse due to uncontrolled withdrawal symptoms, environmental stressors, alcohol use, negative or positive mood, psychiatric instability, or being around other smokers or tobacco users? Were there factors (e.g., fatigue, life disappointments, family or other social stressors) that undermined abstinence? What did the patient learn from prior failures? Past efforts to quit may also influence a patient's readiness and motivation to try quitting again. Thus, it is also important to understand the changes that a patient thinks need to occur before he or she can make another attempt to quit tobacco use, his or her fears about quitting, and the barriers to another attempt to quit.

For patients who have returned to tobacco use despite past efforts at treatment, a first consideration is the adequacy of prior treatment. For example: What was the duration of therapy? How many sessions of behavioral therapy were attended? What was the quality of the behavioral treatment in the last attempt to quit? What were the doses of gum or patch used? What was the level of adherence with the psychosocial or somatic therapy? It is also helpful to determine the patient's satisfaction with prior treatments. For example, did he or she believe that treatment was helpful? Did treatment experiences change his or her expectations of future treatment or its outcome?

The assessment of psychiatric patients in terms of cessation of tobacco use focuses on a number of other key points:

  1. Is the patient motivated to quit using tobacco in the next month?

  2. Are there any psychiatric reasons for concern about whether this is the best time for cessation? Is the patient about to undergo a new therapy? Is the patient presently in crisis? Is there a problem that is so pressing that time is better spent on this problem than on cessation of tobacco use?

  3. What is the likelihood that cessation would worsen the non-nicotine-related psychiatric disorder?

  4. Are there any signs or symptoms of other undiagnosed psychiatric or substance use disorders that might interfere with efforts to quit tobacco use?

  5. What is the patient's ability to mobilize coping skills to deal with cessation?

  6. What is the tobacco use status (e.g., never smoked, former smoker, current smoker) of others in the patient's household and among the patient's close friends?

  7. What are the patient's treatment preferences and the basis for these preferences?

A discussion of the impact of these factors on the approach to treatment can be found in Section III.D, below.

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C. Treatment Settings

With the exception of patients hospitalized for other reasons, treatment of nicotine dependence occurs on an outpatient basis. However, an inpatient model for smoking cessation has been described (717) and appears to produce high cessation rates, especially given the level of nicotine dependence among smokers who enroll. There are no controlled trials that substantiate this at the current time.

Regardless of the specific setting, treatment best occurs in a system that encourages cessation (33). This may be especially important to achieve on psychiatric inpatient units, as discussed below in Section III.G. The psychiatrist should also consider maintaining a smoke-free work site (33, 34).

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D. General Approach to Treatment

As with treating other substance use disorders, the general goals in treating nicotine dependence include motivating and engaging an individual in treatment to reduce or preferably cease using tobacco. However, the general approach to treatment of nicotine dependence will depend on a number of factors, including the patient's psychiatric status, level of nicotine dependence, past treatment and efforts at quitting tobacco use, and current motivation for reducing or quitting tobacco use. This section discusses the general approach to nicotine dependence treatment; specific aspects of the pharmacotherapy and psychosocial treatments of nicotine dependence are discussed in Sections III.E and III.F, respectively.

Meta-analyses have found that the general techniques described below increase rates of quitting by a factor of 1.5–2.0 (718–721). Descriptive reviews of the skills and techniques critical to smoking interventions have also been published (33, 172, 722–728).

Research shows that 98% of tobacco use involves cigarettes, and most of the studies of treatments for nicotine dependence and smoking cessation have been in cigarette smokers (602). The available evidence suggests that other forms of tobacco use (e.g., pipe, cigars, smokeless tobacco) are becoming increasingly common (692). Although studies of treatment interventions are limited, pipe and cigar use are associated with higher rates of nicotine dependence because of their higher nicotine content. Thus, these other forms of nicotine use should also be taken into consideration in the assessment and treatment planning process.

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1. Establishing and maintaining a therapeutic framework and alliance

Nicotine dependence is a chronic relapsing disorder; most smokers require five to seven attempts before they finally quit for good (729). Many patients do not realize that several attempts are often needed to stop smoking, and they will need to be remotivated to attempt to quit after a previous failure (33). Because of this, it is important to establish a therapeutic relationship so that the patient will accept treatment for subsequent attempts to quit, if necessary (33).

Clinician advice for individuals attempting to quit tobacco use is best given in a nonjudgmental, empathic, and supportive manner (32, 33). No studies have been conducted to test whether confrontational interventions applied in treating other substance use disorders are useful with nicotine dependence. In patients with a present or past psychiatric disorder, it is important to convey the message that simply having a psychiatric disorder is not a reason not to make a quit attempt (725, 730).

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2. Increasing readiness and motivation for smoking cessation

A patient's current motivation will determine what strategies should be used to enhance and support his or her readiness and attempts to quit smoking. Because many psychiatric patients are ambivalent about stopping smoking or are not ready to attempt to quit (731–733), nicotine dependence treatment will most often consist of enhancing their motivation and dealing with anticipated barriers to cessation (33).

Brief advice from a physician (using protocols similar to those recommended by the National Cancer Institute) to stop smoking typically doubles quit rates, from approximately 5% to 10% (718–721, 734, 735). Advice from nonphysicians is also effective (718, 721), and advice from multiple sources is more effective (718, 721). Thus, clear direct advice from the psychiatrist and other psychiatric personnel (e.g., nurses, social workers) to stop smoking is an essential initial therapeutic step that may increase patient readiness and motivation to try other therapies as needed.

Stages-of-change approaches and motivational enhancement models (32, 736) may help formalize interventions to enhance a patient's motivation. Such interventions will generally include providing information and feedback on the risks of smoking and reasons for quitting that are specific to the individual patient. The most common reasons for trying to stop smoking are to improve health and respond to social pressure (737). Revisiting the issue of smoking cessation at periodic intervals, especially with the occurrence of smoking-related medical conditions (e.g., bronchitis) or other special situations (e.g., pregnancy, living with a child with asthma), can sometimes motivate smokers to consider quitting (737–740). Documenting smoking status (as well as concurrent alcohol or other drug use) in the medical record may help facilitate such a follow-up.

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3. Overcoming barriers to smoking cessation

Patients who smoke may express negative feelings or fears related to quitting that may serve as a barrier to their smoking cessation. The most common concerns are fear of weight gain, fear of withdrawal, and fear of failure (737). Women frequently cite the fear of weight gain or actual weight gain after quitting smoking as negative reinforcers contributing to smoking relapse. The exacerbation of psychiatric symptoms is likely to be an additional barrier for psychiatric patients (32). There is little evidence that smoking cessation can exacerbate psychiatric symptoms in patients diagnosed with schizophrenia or major depression whose symptoms are stabilized. However, any patient fears about withdrawal symptoms or a worsening of psychiatric problems may be dealt with by problem-solving approaches, increased monitoring by the clinician, behavioral therapy, or treatment with NRT, bupropion, or both.

Patients who smoke may also be uninformed and demoralized about their inability to change or may be defensive and resistant to change. Thus, it may be helpful for a clinician to clarify and legitimize patients' feelings, explore the reasons for their smoking, and offer expressions of support and respect. If feelings of demoralization are uncovered, they can be addressed by informing the patient that even smokers who are very committed to quitting may make several attempts to quit before they finally succeed. Patients who become chronically ambivalent about quitting may benefit from encouragement to take small steps toward their goal of quitting, such as reducing the number of cigarettes they smoke or trying to quit for just 24 hours. The psychiatrist supports self-efficacy by identifying and praising past behavioral change and encouraging the use of strategies that were effective in the past.

Smoking by others in the household and close friends may also present a barrier to treatment. Whether and how others in the household and friends have supported or undermined a patient's prior attempts to quit should be evaluated. Conversely, social support is a major predictor of cessation (741). If others in the household are current smokers, it is useful to determine their willingness to quit at the same time as the patient or not to smoke in front of the patient.

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4. Eliciting patient preferences about treatment

Patients' treatment preferences and the reasons for those preferences should be elicited and considered when developing a treatment plan. For example, some patients may prefer to stop smoking on a certain date or may have strong likes or dislikes about pharmacotherapy, group therapy, or individual therapy. These factors will be important in setting a specific quit date as well as enhancing the patient's adherence to the treatment plan.

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5. Determining timing of smoking cessation

When and how cessation advice is best delivered must be determined by the patient's status; for example, smoking cessation is not likely to be successful when the patient is in crisis. The best time for cessation would appear to be when the patient is psychiatrically stable, there are no recent or planned changes in medications, and no urgent problems take precedence (730). On the other hand, admission to a smoke-free inpatient unit or integrating smoking cessation into other lifestyle changes that are a part of ongoing psychiatric treatment (e.g., during cessation of alcohol use) can sometimes motivate a patient to quit smoking. More immediate cessation is indicated if the patient has recently been diagnosed with a smoking-related medical disorder; individuals with such disorders generally have high success rates for quitting (737, 740). Whenever a smoking quit date is postponed, it is helpful to list smoking cessation as a goal on the master psychiatric treatment plan so that it can be addressed at a later time.

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6. Determining whether smoking cessation will be abrupt versus gradual

Most patients attempt and most clinicians recommend abrupt cessation of smoking rather than gradual reduction (742). Previous thinking has held that gradual reduction is less successful because patients appear to have difficulty achieving further reductions once they have cut down smoking to 5–10 cigarettes per day (173). On the other hand, most of the scientific data available suggest no difference in the outcomes of abrupt versus gradual cessation (173, 718, 719, 743); thus, patient preference to follow a gradual reduction strategy should be respected. A gradual approach may also be considered if the patient is historically uninterested or unable to quit smoking, as a significant and sustained reduction in smoking might still be achievable. Whether reductions in smoking are related to decreasing risk for smoking-related medical illnesses has not been clearly established (744, 745).

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7. Setting a quit date

Once the above factors have been addressed and the patient agrees to stop smoking, a specific quit date is set and a concrete discussion of cessation procedures occurs. In addition, the psychiatrist may give the patient written materials that provide suggestions for succeeding in quitting. Even if a gradual approach to smoking cessation is chosen, patients should generally be advised to set a date by which they will completely stop smoking and that they should not use NRT until they have stopped smoking. Because many patients relapse within the first few days of smoking cessation (746), it is important for the psychiatrist or the psychiatrist's staff to call or see the patient in the first 1–3 days after the quit date.

If the patient is not ready to make a commitment to a quit date, the psychiatrist should plan to readdress smoking at a later date, encourage the patient to reconsider, and offer to help if the patient changes his or her mind. In addition, the psychiatrist may give the patient written materials that are intended to motivate the patient to make a quit attempt or that give tips on how to successfully quit.

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8. Developing a plan of psychosocial and pharmacological treatment
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a) Initial approaches

In the general population, most smokers quit on their own or with minimal treatment (747); for those who are unable to stop with minimal intervention, many algorithms and guidelines recommend a stepped-care approach, with minimal intervention early on and more intensive intervention later in the course of treatment (140, 172, 748–750). At the same time, most smokers who quit on their own require several attempts before they succeed (750); thus any success later in the algorithm cannot be attributed to the specific treatment being given at that point. Just as important, early cessation of smoking can prevent much of the devastating consequences of smoking (751); thus, delaying delivery of a treatment known to be effective could allow a serious, irreversible consequence of smoking (e.g., acute myocardial infarction, lung cancer) to develop. Consequently, the availability of effective treatments for smoking cessation as well as the rarity of significant adverse effects of those treatments suggests that pharmacotherapy be offered to all patients who wish to stop smoking. Combining psychosocial and medication treatment generally produces the best outcomes; however, medications are effective even when no psychosocial treatment is provided.

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b) Monitoring clinical status

After the first follow-up 1–3 days after the quit date (see Section III.D.7), additional follow-ups may be scheduled, depending on the patient's perceived need, history of cessation, and psychiatric history. Follow-up visits may also be needed to assess a medication blood level that might increase with cessation. Follow-up visits may also be needed to monitor side effects or plan tapering of antismoking medications.

At follow-up, the psychiatrist assesses whether the patient has smoked and, if so, the number of cigarettes smoked per day; the severity of the patient's withdrawal symptoms; the onset of any psychiatric symptoms; the patient's use of alcohol or other drugs; how the patient dealt with situations in which he or she felt a strong urge to smoke; medication side effects; and other relevant issues and then tailors treatment accordingly (33). Most but not all studies suggest that brief follow-ups (including telephone calls) increase quit rates (720, 721, 752–754).

+ (1) Identifying symptoms of withdrawal

Nicotine withdrawal symptoms typically begin a few hours after the patient has ceased smoking and include dysphoric or depressed mood; insomnia; irritability, frustration or anger; anxiety; difficulty concentrating; restlessness; decreased heart rate; and increased appetite or weight gain. Although most symptoms peak 24–48 hours after cessation, they last an average of 4 weeks, with hunger and craving for tobacco lasting 6 months or more in some individuals (755). The duration of nicotine withdrawal symptoms may be a more important determinant of smoking relapse than the severity of the symptoms (756). Smoking cessation can cause physiological problems such as slowing of electroencephalographic activity in the awake and sleep state, decreases in cortisol and catecholamine levels, and a decline in the patient's metabolic rate (757). The mean heart rate decline is about 8 bpm, and the mean weight gain is 2–3 kg (757).

Nicotine withdrawal can occur in association with all forms of tobacco use (cigarettes, chewing tobacco, snuff, pipes, cigars) as well as with NRTs (755, 757). The ability of these products to induce or maintain dependence and withdrawal increases with the rapidity of the absorption of nicotine, the nicotine dose, and the availability of the product (758). Consequently, although symptom severity varies among patients (757), withdrawal is usually most severe with cigarette abstinence compared with abstinence from other forms of tobacco and nicotine medications (755, 757, 759).

+ (2) Identifying exacerbations of psychiatric symptoms

Patients with current or past psychiatric symptoms or disorders need particularly close monitoring in the first 14 days after smoking cessation because nicotine withdrawal symptoms such as anxiety, depression, increased rapid eye movement sleep, insomnia, irritability, restlessness, and weight gain can mimic, disguise, or aggravate the symptoms of other psychiatric disorders or side effects of medications. For example, when an alcohol-dependent individual who is also nicotine dependent is admitted to a smoke-free ward for alcohol detoxification, his or her anxiety, depression, difficulty concentrating, insomnia, irritability, and restlessness could be due to or aggravated by nicotine withdrawal. Although more studies support concurrent attempts to quit smoking and drinking, there is one study that suggests that relapse to alcohol is more likely with concurrent smoking cessation (38). There have been several prospective studies (760, 761) that have examined whether smoking cessation can exacerbate depressive (762–766) or psychotic (414, 702, 703, 767) symptoms in patients with major depression and schizophrenia, respectively; most of the available evidence suggests that this risk is low when patients' psychiatric symptoms are stabilized prior to the cessation attempt.

A patient's psychiatric status should also be monitored because blood levels of some psychiatric medications (e.g., those metabolized by the CYP 1A2 microsomal system, including clozapine, fluphenazine, haloperidol, oxazepam, desmethyldiazepam, clomipramine, nortriptyline, imipramine, desipramine, doxepin, and propranolol) may increase substantially within 3–6 weeks when patients taking such medications stop smoking, and these increases could worsen side effects or cause toxicity (414, 698, 760, 768, 769). This effect appears to be due not to nicotine but rather to the effects of benzopyrenes (tobacco carcinogens) and related compounds on the P450 system.

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9. Providing education and enhancing adherence

Many patients do not realize their smoking may be a form of nicotine dependence (770). Key points to convey to patients include the following: 1) most smokers try to quit multiple times before they finally succeed, but with persistence, half of all smokers quit; 2) most smokers fail early on, but if the smoker is able to remain abstinent for 3 months, relapse is unlikely; 3) nicotine withdrawal can be relieved with NRT; 4) true withdrawal symptoms generally last 4 weeks or longer and may include dysphoric or depressed mood, insomnia, irritability, frustration or anger, anxiety, difficulty concentrating, restlessness, decreased heart rate, increased appetite, or weight gain (33).

To support a patient's adherence to treatment, it is important to deal with the patient's concerns about weight gain. Even though the health benefits of stopping smoking clearly outweigh the health risks of weight gain (771), fear of weight gain is common and is a major deterrent to smoking cessation, especially in women (772, 773). On average, smokers weigh 2–3 kg less than individuals who have never smoked, and when smokers stop smoking, they gain weight until they are similar in weight to those who have never smoked (771). Most smokers gain weight over the first few months after quitting smoking, but many later lose much or all of this weight. Women who are already trying to decrease their weight gain the most (773). However, smoking cessation-related weight gain does not cause a relapse to smoking (755). In fact, a concentrated effort to control weight gain by dieting during abstinence increases, not decreases, the chances of a relapse to smoking (774, 775). This may be because attempting to quit smoking and dieting at the same time is just too difficult. Clinicians can recommend that patients increase their physical activity and learn healthy eating strategies rather than diet or convince patients to tolerate a moderate amount of weight gain over the first 3 months after smoking cessation and work on losing weight later (775). Nicotine gum, but not the nicotine patch, appears to delay weight gain and could be used to delay attempts to control weight until a relapse to smoking is less likely (776).

Alcohol use is a risk factor in most studies for relapsing to smoking (777); thus, it is recommended that patients who are attempting to quit smoking either diminish their alcohol intake or abstain from alcohol. Caffeine use typically does not change with smoking cessation (755), and it is unclear whether caffeine use is a risk factor for relapse (769). Smoking increases the metabolism of caffeine, and smoking cessation increases caffeine levels by 50%–60% (778). Because many of the symptoms of caffeine intoxication and nicotine withdrawal overlap (e.g., anxiety, insomnia, restlessness), reducing caffeine intake after smoking cessation might be helpful; however, the one study to test this hypothesis found caffeine does not increase the severity of tobacco withdrawal (778). In addition, abruptly stopping caffeine could induce a withdrawal syndrome of its own (779). In summary, with this contradictory evidence, patient preferences on whether to change caffeine intake should be respected.

Because smoking even one cigarette during a cessation attempt often portends a full-blown relapse (780), reports of any slips should prompt immediate planning around changes in behavioral therapy (e.g., discuss ways to avoid or cope with the situation that led to the slip) or changes in pharmacotherapy (e.g., increased dose, change in medication). If the patient has fully relapsed, the psychiatrist should praise the patient for even limited success. The patient and psychiatrist should then discuss what was learned with this quit attempt and when the patient would like to think about trying again. Most patients who relapse continue to be interested in stopping smoking; thus, the psychiatrist should discuss setting a time to reconsider another cessation attempt.

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10. Determining approaches for patients who do not respond to initial treatment

When a patient does not respond to a trial of a known effective formal therapy (e.g., behavioral therapy, NRT, bupropion, a combination of these therapies), it is first important to determine if the treatment was adequately or inadequately implemented. If inadequately implemented, the therapy may be repeated with changes to ensure the fidelity to therapeutic steps, treatment adherence, and adequacy of treatment dose and duration.

If the treatment was both appropriate and adequately implemented, rescreening the patient for other co-occurring disorders is indicated, as other unrecognized substance use or psychiatric disorders can interfere with smoking cessation (698, 760, 781). The psychiatrist should also attempt to determine whether the relapse was related to withdrawal symptoms or other causes. If the patient has not previously been treated with NRT and the prior relapse appeared to be caused by withdrawal symptomatology, NRT is appropriate. If the patient has been adequately treated with NRT, the psychiatrist may consider bupropion and/or a different formulation or dose of NRT. If these approaches are also ineffective, the use of clonidine or nortriptyline could be considered.

Other NRT delivery systems can also be considered. Although its side effects can limit its acceptability to some patients, nicotine nasal spray produces a more bolus-like effect that might better relieve withdrawal symptoms and craving (782), especially in heavy smokers who report that they relapsed to smoking both for withdrawal relief and for the positive effects of nicotine and tobacco (e.g., liking, satisfaction). A nicotine inhaler has the added advantage of replicating the hand-to-mouth motor acts associated with smoking, which may further support its utility. A strategy of initially using nicotine nasal spray and then switching to a nicotine patch or concomitantly using nicotine nasal spray and patch has been proposed and received some empirical support from controlled studies (782a, 782b, 1563). The combination of a patch with a faster-acting NRT such as gum, lozenge, spray, or inhaler may have some rationale, as the patch provides a steady level of nicotine for withdrawal relief and the faster delivery systems address the positive aspects of smoking (satisfaction and liking).

If the patient has relapsed because of a stressful life event and has not previously been treated with behavioral therapy, this type of therapy should be considered. If the patient has already had behavioral therapy, two choices are available: 1) more intensive behavioral therapy or 2) behavioral therapy within a different content or format (e.g., group therapy, individual therapy, combined individual and group therapy, involvement of family members). Whether these treatments are effective for those who have not responded to prior behavioral therapy has not been studied. Sometimes it is difficult to distinguish withdrawal versus nonwithdrawal causes of relapse. Under such circumstances, the patient may be a candidate for combined pharmacological and behavioral therapy (783, 784).

The results of three small controlled studies of acupuncture are promising (785–787), but due to methodological limitations, they do not justify the use of acupuncture for treating nicotine dependence either alone or in combination with other treatments. Furthermore, a meta-analysis of 22 controlled studies suggests acupuncture lacks efficacy in promoting smoking cessation (788).

When the treating psychiatrist does not have the knowledge necessary to implement the treatments outlined herein, or if the strategies are administered and the patient is not able to quit smoking, the psychiatrist should consider referring the patient to someone who specializes in treating nicotine dependence.

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E. Somatic Treatments

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1. Nicotine replacement therapies

NRTs can be used as a first-line treatment approach for any individual who wishes to stop smoking. At present, there are five FDA-approved forms of NRT: patch, gum, lozenge, nasal spray, and inhaler. Because all are effective in alleviating withdrawal symptoms (789) and reducing smoking (790) in men and in women (791, 792), the choice of a specific NRT typically depends on patient preference and the NRT's route of administration and side effect profile (793). It is unclear what adjustments to NRTs are needed for pipe and cigar users; probably these therapies should be implemented according to the patient's nicotine dependence level as measured by the Fagerström Test (794). Using a combination of NRTs (790) or combining NRT with bupropion (795) or psychosocial therapies (790) may improve outcome.

The optimal duration of NRT is debatable (693). Although some individuals appear to require long-term use of NRT (e.g., 6 months), almost all eventually stop using such agents, and the development of dependence on these agents is rare (796, 797). Thus, patient preference should be the major determinant for the duration of an NRT.

Of the NRTs, many individuals find it easier to adhere to nicotine patch therapy. Typically, nicotine patch therapy will begin with a high-dose patch (21 or 22 mg); however, patients who smoke <15 cigarettes per day are candidates for starting with an intermediate-dose patch (e.g., 11 or 14 mg) or for using another form of NRT (798). Whether the 24- or 16-hour patch is better is debatable (71, 798). The 24-hour patch may better relieve morning craving but appears to cause insomnia in some patients (799, 800). Other common side effects are skin irritation (which can be diminished by rotating patch placement sites), nausea, and vivid dreams; however, patients usually develop tolerance to these side effects (790, 801). The recommended duration of nicotine patch therapy is 6–12 weeks, with a tapering of the patch dose over that period; longer durations of patch therapy have not been found to be more effective (790).

When nicotine gum or lozenges are used, scheduled dosing (e.g., one 2-mg lozenge or piece of gum every hour) rather than ad libitum dosing is often best. The 4-mg dose is recommended for heavy smokers (>25 cigarettes/day) or more nicotine-dependent smokers (790, 802, 803). The dose of nicotine replacement can be tapered over 6–12 weeks by decreasing the gum or lozenge dose (i.e., from 4 to 2 mg) and/or increasing the time between doses. Patients also benefit from receiving instructions about proper use of these NRTs. With nicotine gum, patients should be instructed to chew one piece of gum very slowly until a slight tingling or distinctive taste is noted, at which time the gum should be placed ("parked") between the cheek and gum until the taste or tingling is almost gone. This process is then repeated over about 30 minutes for each piece of gum. Nicotine lozenges should be sucked on rather than bitten or chewed. Typical side effects of lozenges are minor but include nausea, heartburn, and mild throat or mouth irritation; side effects of the gum are jaw soreness or difficulty chewing (802, 804). In addition, the lozenge contains phenylalanine and should not be used by individuals with a history of phenylketonuria. With both the lozenge and the gum, it is important to avoid beverages other than water immediately before or during NRT use because associated pH changes can blunt nicotine absorption (804a).

Nicotine nasal spray and vapor inhaler systems provide faster delivery of nicotine than gum or lozenges, but still deliver nicotine more slowly and with lower peak nicotine levels than cigarettes. Nicotine nasal sprays produce droplets that average 1 mg per administration, and patients administer the spray to each nostril every 1–2 hours. Nicotine vapor inhalers are cartridges of nicotine that are placed inside hollow cigarette-like plastic rods and produce a nicotine vapor (0.013 mg/puff) when smokers puff on them (805, 806). The recommended dose is 6–16 cartridges daily, with the inhaler being used ad libitum for about 12 weeks. Short-term side effects from nicotine nasal spray include nasal and throat irritation, rhinitis, sneezing, coughing, and watering eyes in up to 75% of users (807–809), and nicotine inhaler use is most often associated with throat irritation or coughing in up to 50% of users (806, 810). When compared with other forms of NRTs, the nasal spray and inhaler may have somewhat higher rates of continued use for periods >6 months (782, 796, 811).

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2. Bupropion

The antidepressant agent bupropion in the sustained-release formulation is a first-line pharmacological treatment for nicotine-dependent smokers who want to quit smoking. Bupropion appears to have comparable tolerability and effectiveness to NRTs (158–160, 795, 812) and is equally beneficial in men and women (813). The target dosage for individuals with nicotine dependence is 300 mg/day. The medication is initiated at 150 mg/day 7 days prior to the target quit date; after 3–4 days, dosing is increased to 300 mg/day (150 mg b.i.d.). Bupropion can also be used in combination with an NRT, although the evidence is mixed on the extent to which this improves outcomes (795).

The primary side effects associated with bupropion are headache, jitteriness, insomnia, and gastrointestinal symptoms (795). Caution is needed when prescribing bupropion to individuals with a history of seizures of any etiology, as seizures have also been observed with bupropion treatment. The use of bupropion, especially the short-acting preparation, is also discouraged in patients with a past, and particularly a current, diagnosis of an eating disorder (i.e., anorexia nervosa or bulimia nervosa) because of higher rates of seizures observed in initial studies of the medication (161). In other individuals, the rate of de novo seizures is low (<0.5%), and such seizures are predominantly observed when daily dosing exceeds 450 mg/day (795).

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3. Other agents

There is also support for the use of nortriptyline and clonidine as treatments for nicotine dependence; however, given the number of other available treatments for which results are well validated, these should be viewed as second-line therapies. Nortriptyline may be particularly promising as a second-line nonnicotine pharmacotherapy, and its efficacy does not appear to depend on the presence of co-occurring depressive symptoms or major depressive disorder (795, 814). However, the side effects of nortriptyline are more prominent than those of NRTs or bupropion, and nortriptyline is also toxic in overdose amounts (455, 815–817). Clonidine may also have some merit as a second-line agent (818), but its side effects may limit its use (819). Acupuncture (788) and other agents (e.g., naltrexone, mecamylamine, buspirone, monoamine oxidase inhibitors [MAOIs], SSRI antidepressants) (603, 795, 820–823) have also been studied, but their efficacy for smoking cessation has not been established.

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F. Psychosocial Treatments

There is extensive evidence of the efficacy of psychosocial therapies for treating individuals with nicotine dependence, whether delivered in a group (824) or individual (825) format. These therapies are typically provided as a multimodal package of several specific treatments and aim to provide patients with the skills to quit smoking and avoid smoking in high-risk situations. Behavioral coping skills may include removing oneself from the situation, substituting other behaviors (e.g., walking, exercising), or using skills to manage triggers (e.g., assertiveness, refusal skills, time management). Cognitive coping skills may include identifying maladaptive thoughts, challenging them, and substituting more effective thought patterns to prevent a slip from becoming a relapse (e.g., not viewing the slip as a catastrophe). The 6-month quit rates for behavioral therapies in general are typically 20%–25%, or about twofold greater than quit rates with control conditions (824–828). A review of behavioral therapy studies also suggests that 1) more intensive behavioral therapies can produce better treatment outcomes versus low-intensity interventions (701, 703), and 2) behavioral therapies can augment smoking cessation outcomes with pharmacotherapies, including all NRTs and bupropion (414, 701, 703, 704).

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1. Social support

Social support appears to be of benefit in encouraging an individual to quit smoking, whether it is measured according to the degree of support provided by a spouse or partner (829) or is provided in the form of a specific intervention (e.g., buddy system) (718, 826, 828, 830–833). Thus, social support is recommended as a treatment for smoking cessation.

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2. Brief therapies

Brief therapies, such as behavioral supportive cessation counseling, may lead to enhanced rates of treatment retention or smoking cessation (639, 826, 828, 834–837). Such therapies can often be implemented successfully and economically in a broad range of health care settings. These therapies often incorporate elements of MET and encourage the patient to examine the reasons for and against quitting smoking. When brief interventions are used, patients are likely to have a greater number of quit attempts and a greater likelihood of success in smoking cessation (825, 826, 828).

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3. Behavioral therapies

Behavioral therapies are recommended as a first-line treatment for smoking cessation, with a large database of over 100 controlled prospective studies on multimodal behavioral therapy supporting this recommendation (720, 734, 735, 826, 838). In most reviews and meta-analyses, 6-month quit rates with behavioral therapy are double those observed in control groups (824, 826, 828) and similar to long-term outcomes obtained with NRTs and bupropion. Specific types of behavioral therapy that have also been studied include contingency management, cue exposure, and "rapid smoking" aversion therapy; however, none of these are sufficiently well studied to support their use clinically.

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4. Cognitive-behavioral therapies

Several controlled studies suggest that CBTs are effective for smoking cessation (700, 839, 840) and are possibly effective for smokers with comorbid depressive symptoms, major depression, and alcohol and other substance use disorders (456, 459, 841–844). CBT may also help in addressing weight concerns associated with smoking cessation (840). However, the long-term effectiveness of CBT in this population has not been established.

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5. Self-guided therapies

Self-help materials are designed to increase patients' motivation to quit smoking and teach them smoking cessation skills. In most (845–853) but not all (854, 855) studies, approaches such as community support groups, telephone counseling, written manuals, videos, and computer-generated, tailored self-help materials have shown promise in increasing smoking cessation rates. The use of multiple modes of therapy (e.g., written materials plus phone contact) (718, 720, 721, 856–859) and tailoring materials to the specific needs and concerns of each patient improves the effectiveness of self-help methods (736, 851, 860).

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6. Other therapies

A number of other psychosocial therapies have been evaluated in a small number of clinical trials, with the results showing variable success. For example, some evidence suggests that exercise programs may help prevent a relapse to smoking in women (861, 862), whereas other studies do not (863, 864). However, based on the other health benefits of exercise, increased activity is encouraged in smokers attempting to quit or those who have recently quit smoking. There is also some support for the effectiveness of stimulus control techniques in reducing smoking urges, such as discarding cigarettes; removing ashtrays, lighters, and matches; avoiding smokers; and avoiding situations associated with smoking (718). However, these strategies are probably best used within the context of multicomponent therapies. Little evidence is available that would support the use of physiological feedback (i.e., giving immediate positive feedback on the benefits of smoking cessation such as decreasing carbon monoxide levels), gradual cessation (i.e., "nicotine fading"), or relaxation techniques (718). In addition, there is an insufficient number of studies of adequate research design regarding the use of 12-step programs, hypnosis, biofeedback, family therapy, IPT, or psychodynamic therapies for treating nicotine dependence, although clinical consensus suggests that such therapies may be useful in some patients.

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G. Treatment of Smokers on Smoke-Free Wards

This section focuses on the treatment of psychiatric patients on smoke-free wards, a common issue confronted by psychiatrists. The principles described also apply to smokers on general medical wards seen in consultation and to smokers in smoke-free nonmedical settings, such as residential care settings. Controlled studies of treating nicotine withdrawal symptoms on psychiatric inpatient wards have not been published; thus, the recommendations below are based on treating withdrawal in outpatient settings (755, 757).

An inpatient stay may be an opportune time for initiating treatment for nicotine dependence because of the intensity of exposure to medical staff, diagnosis of medical conditions, and removal from usual smoking cues. It may therefore be helpful to include smoking cessation on the master treatment plan whenever relevant. As in other settings, smokers should be assessed for their readiness and motivation for change (32). Those considering quitting should be asked about their interest in using the temporary abstinence of the smoke-free unit as a beginning step toward permanently stopping smoking. In addition to the aspects of assessment discussed above in Section III.B, it may also be helpful to elicit from the patient any history of withdrawal symptoms in prior hospitalizations, withdrawal during prior voluntary quit attempts, or significant fear of withdrawal. An important but often neglected issue is the incorporation of NRTs and smoking cessation-related advice and aftercare into treatment plans on patient discharge (865).

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1. System issues

Although many inpatient units have been concerned about implementing smoke-free units, most have found it less difficult than anticipated (34, 866, 867). Most (34, 866, 868–870) but not all (871) reports before and after the institution of smoke-free units indicate no increases in aggression, disruption, discharges against medical advice, use of medications or restraints, or admission refusals. However, a recent retrospective study on a smoke-free unit suggested that smokers may be more likely to be irritable or agitated than nonsmokers and that smokers who are not prescribed an NRT were more likely to be discharged against medical advice than other patients (865). Giving special off-ward privileges to allow patients to smoke or labeling off-ward passes as "smoking breaks" implicitly condones smoking (34, 866). In addition, there are risks in allowing some patients to have smoking breaks, such as patients with suicidal ideation or those with a history of eloping or exhibiting other problematic behavior on passes. Policies that provide breaks for smokers and nonsmokers on the same schedule may be preferable to policies that provide smokers with extra passes. Other recommendations for implementing a smoke-free unit are discussed in reviews (34, 866).

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2. Patient education

Patients need to be educated about the rationale for a smoke-free unit; that is, that its purpose is not to force patients to stop smoking but to prevent secondhand smoke exposure to other patients and be consistent with the institution's goal to encourage healthy behaviors (34, 866). Patients should also be educated about the goal of smoking cessation treatment: to reduce withdrawal symptoms and, if patients are interested, to help them begin a cessation attempt (see Section III.D.9). Many patients are unaware of the valid symptoms of nicotine withdrawal and their time course; thus education about these can be helpful (34, 866).

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3. Monitoring of symptoms

Although true for all individuals who stop smoking, it is particularly important to monitor patients in smoke-free inpatient settings for changes in psychiatric symptoms. Smoking cessation can worsen anxiety, insomnia, concentration, and weight gain, thereby confounding assessment and treatment of the patient's other psychiatric disorders (865). For example, because many alcohol-dependent patients smoke, it may not be clear whether their irritability, anxiety, insomnia, restlessness, difficulty concentrating, and depression are due to alcohol or nicotine withdrawal during alcohol detoxification on a smoke-free ward. Although nicotine withdrawal symptoms are thought to be milder than alcohol withdrawal symptoms, there is substantial person-to-person variability so that some alcohol-dependent smokers have nicotine withdrawal symptoms that are more severe than their alcohol withdrawal symptoms (872). When patients with schizophrenia are hospitalized and given higher doses of medications to treat acute psychosis, any increases in restlessness could be due to nicotine withdrawal rather than to neuroleptic-induced akathisia. Further confounding the source of the increased symptoms is the fact that smoking cessation can cause dramatic increases in blood levels of some medications (e.g., those metabolized by the CYP 1A2 microsomal system) (760, 873). In particular, clozapine levels can increase by up to 40% with smoking cessation (874).

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4. Treatment of withdrawal symptoms

For some individuals, nicotine withdrawal during hospitalization is often not as severe as anticipated because of the absence of smoking cues, the distraction of the primary psychiatric problem, and the effects of medications. However, a recent retrospective study suggests there are clear benefits of providing NRTs to smokers on smoke-free inpatient psychiatric units (865), findings that are consistent with recommendations of the U.S. Agency for Healthcare Research and Quality's A Clinical Practice Guideline for Treating Tobacco Use and Dependence (826) and with a meta-analysis of studies in nonpsychiatric inpatients (875). Thus, given the low risk of NRTs, prophylactic treatment with an NRT is suggested for all psychiatric inpatients who smoke. The advantages of nicotine gum in this context include the patient's ability to self-titrate the nicotine dose and stop using the gum immediately before intermittent smoking (e.g., during passes). In addition, many patients find that only a few pieces of gum per day are sufficient to prevent withdrawal symptoms (34, 866). The nicotine patch has the advantage of improved adherence and providing stable nicotine replacement. This may be especially advantageous in patients for whom a clinician is trying to differentiate nicotine withdrawal symptoms from psychiatric symptoms (873). For highly nicotine-dependent individuals, the use of more than one form of NRT (e.g., nicotine patch plus gum) may be helpful (865). A frequent question about prescribing NRT to patients on smoke-free units relates to those individuals who do not wish to stop smoking entirely and may use NRTs and cigarettes concurrently. However, such use of NRTs appears to be unlikely to produce significant adverse effects (865, 876–881). Bupropion can also be used in inpatient settings given its fixed dosing, easy monitoring, and efficacy in reducing signs and symptoms of the withdrawal syndrome (158).

Although the existing evidence does not show direct effects of psychosocial treatments on withdrawal symptoms, clinical experience suggests several strategies that may be useful for individuals in inpatient settings. Relaxation tapes can be used to alleviate anxiety. Anger can be averted by temporarily avoiding interactions; insomnia can be decreased by improving sleep hygiene; weight gain can be combated by increasing activity; and distraction and activities aimed at keeping busy can be used to get through craving episodes. Support groups for those going smoke free and support from family and significant others for going smoke free can be helpful as well.

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H. Clinical Features Influencing Treatment

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1. Use of multiple substances

There is strong evidence that rates of smoking are much higher in patients with a substance use disorder than in the general population (347). For example, in the National Epidemiologic Survey on Alcohol and Related Conditions, the 12-month prevalence of nicotine dependence is 34.5% among individuals with any alcohol use disorder and 52.4% among individuals with any drug use disorder (347). Conversely, among subjects with nicotine dependence, the 12-month prevalence of an alcohol use disorder is 22.8% and that of a drug use disorder is 8.2%, rates that are 4.4- and 8.1-fold higher, respectively, those observed in non-nicotine-dependent individuals (347). A similar association between nicotine dependence and other substance use disorders has been observed in data from the National Comorbidity Study (349). In addition, the presence of alcohol or illicit drug use may be a negative predictor of smoking cessation treatment outcomes (698, 872). Although substance use and smoking are often concurrent and conditioned effects may be one important factor in determining the high rates of comorbidity and treatment failure, rates of smoking cessation among these individuals can still be substantial (349). In addition, many individuals with a substance use disorder express an interest in smoking cessation. In patients who do not express a current interest in quitting, motivational interventions should be used.

There is conflicting evidence about whether concurrent smoking cessation can increase, decrease, or affect at all the risk of relapse to alcohol (38), and it is also unclear whether cessation should be attempted concurrently or after initial abstinence from other substances. For these reasons, this decision may be guided by patient preference. In addition, there are few studies of pharmacotherapies in individuals with substance use disorders (705), but there is some evidence for the utility of NRT and behavioral approaches. The use of alcohol treatment-related pharmacotherapies such as disulfiram or naltrexone might be considered in alcohol-dependent smokers, but there are no empirical studies to suggest the efficacy of these therapies in smoking cessation. In any case, such smoking cessation treatment should be made available in substance use disorder treatment programs.

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2. Treatment in the presence of specific co-occurring psychiatric disorders

In the presence of a co-occurring psychiatric disorder, smoking cessation may be more difficult (349, 698, 760, 882). Psychiatric patients appear to have more withdrawal symptomatology when they stop smoking (414, 703, 767), probably as a function of their higher levels of nicotine dependence and smoking consumption. Cessation rates with NRTs (702, 703, 883) appear promising in patients with serious psychiatric disorders. Nicotine nasal spray and vapor inhaler systems provide faster delivery of nicotine, which may increase the rewarding effects of their use. However, no specific studies on these systems have been published in psychiatric patients, and the degree of difficulty of using these delivery systems and their side effects may limit their utility in this population (758, 884). Although many psychiatric patients smoke large numbers of cigarettes and inhale cigarette smoke deeply (885), using higher-than-normal doses of nicotine for heavier smokers has not been consistently shown to be more effective (790, 886). However, supplementation of the nicotine patch with ad libitum use of nicotine gum, lozenges, or inhaler appears helpful (887, 888). NRTs may also be considered as a way to reduce smoking even when patients do not have smoking cessation as a goal.

Initial psychosocial interventions for psychiatric patients may need to include higher intensities of behavioral therapy, because briefer psychosocial treatments are often unsuccessful (414, 702–704). There has been little study of behavioral therapies for smoking cessation in chronic psychiatric patients, although preliminary studies provide modest evidence that higher-intensity therapies may improve outcomes (701, 703). These studies have typically lacked a treatment as usual or minimal intervention controls, necessitating more controlled studies to establish the efficacy of these treatments. Combining higher-intensity behavioral treatments with an NRT or bupropion should be considered and has shown some modest success rates in preliminary studies (414, 701, 703, 704). In addition, psychiatric patients, including those who abuse or are dependent on substances, are more likely to benefit from behavioral therapy because of their high incidence of psychosocial problems, poor coping skills, and often, history of benefit from such therapy (730). When deciding between individual or group therapy, it is important to consider patient preference, as many psychiatric patients have experience with one or both kinds of psychotherapy. For some patients, both individual and group therapy may be indicated; for example, a specific problem that undermines cessation (e.g., a problem with assertiveness) might be addressed by individual therapy, whereas smoking cessation in general might be addressed in group therapy. Patients with low levels of coping skills or supports might also benefit from both individual and group behavioral therapy.

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a) Schizophrenia

Rates of smoking in patients with schizophrenia are much higher (58%–88%) than in the general population (349, 889). The motivation to address smoking is often poor in these patients (882, 890), and thus motivational interventions as initial treatments are strongly suggested (891). In addition, the very low quit rates observed for these patients (349) suggest that more intense interventions are needed. Several controlled trials (414, 701–704) using combinations of higher-intensity behavioral support and pharmacotherapies (NRTs or bupropion) have shown modest short-term cessation rates, whereas one open-label trial of bupropion and supportive group therapy showed a decreased consumption of cigarettes in patients with schizophrenia (415). Concurrent alcohol and drug abuse in individuals with schizophrenia is high and can complicate cessation efforts; most studies have attempted cessation in patients whose drug use is in recovery and whose psychiatric symptoms are stable. Regular monitoring of antipsychotic side effects and plasma concentrations may be needed because smoking cessation may increase levels of antipsychotic medications that are metabolized via the CYP 1A2 system (e.g., clozapine, olanzapine, fluphenazine, haloperidol) (see Section III.D.8.b.2). There is some evidence that in smokers with schizophrenia, the use of second-generation antipsychotic agents can either reduce smoking (e.g., clozapine) in those not wanting to quit (407) or facilitate cessation in those attempting to quit with the nicotine patch (703) or bupropion (414), but further studies of this effect are needed in larger samples.

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b) Depressive disorders

Individuals with major depressive or dysthymic disorder also have high rates of smoking, with 12-month prevalence rates of about 30% (347). Similarly, about 17% of nicotine-dependent individuals have a 12-month prevalence of major depressive disorder (347), and 40% of smokers seeking treatment have a history of depression (760, 781). Current (765, 892, 893) and perhaps past (894) depression appears to be a negative predictor of treatment outcome during smoking cessation. Although pharmacotherapies for smoking cessation have not been carefully tested in patients with current (458) or past (456) major depression, antidepressants such as bupropion (158) or nortriptyline (456) should be strongly considered. In general, SSRIs do not appear to be efficacious in promoting smoking cessation (602, 795). Behavioral therapies such as CBT should also be considered for depressed smokers (456, 459, 893, 895), as these individuals are likely to fail with more minimal interventions. After a patient has quit smoking, his or her plasma levels of some antidepressants (e.g., TCAs) that are metabolized by CYP 1A2 may increase, necessitating close monitoring of levels and antidepressant side effects.

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c) Other psychiatric disorders

Smoking rates in patients with a bipolar or anxiety disorder (e.g., PTSD, panic disorder), ADHD, or another substance use disorder (e.g., marijuana, opioids, cocaine) are also higher than in the general population, but there has been little study of factors associated with these patients' interest in quitting smoking or the efficacy of smoking cessation interventions with these patients (698, 699).

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3. Comorbid general medical disorders
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a) General issues

Nicotine dependence is the most frequent substance use disorder in all medical settings. In 2001, an estimated 46.2 million adults in the United States smoked cigarettes (896). A 2004 report of the U.S. Surgeon General (897) concluded that there is sufficient evidence to infer a causal relation between smoking and many medical conditions, including cancer and cardiovascular and respiratory diseases. Despite improved public awareness of its dangers, tobacco use continues to be the leading preventable cause of disease and death in the United States, leading to approximately 440,000 deaths per year (898). Because the duration of smoking is a substantial contributor to the associated harms from inhalation of tar and carbon monoxide, early intervention is important if smoking-related morbidity and mortality are to be prevented.

It is not surprising that smokers with psychiatric disorders have an increased risk for nicotine-related medical disorders because individuals with a psychiatric and/or a substance use disorder are two to three times more likely to be dependent on nicotine than the general population (347) and smokers with psychiatric disorders consume nearly half of all the cigarettes consumed in the United States (349). In addition, many of these individuals are obese, consume harmful levels of alcohol and salt, and do not exercise or undergo cholesterol screenings (899). As well as having increased medical comorbidity, smokers on psychiatric or other medications that are metabolized through CYP 1A2 will require higher medication doses compared with nonsmokers (414, 698, 760, 768, 769).

Environmental tobacco smoke (secondhand smoke) also contributes to increased morbidity and mortality and has been classified by the U.S. Environmental Protection Agency as a known cause of lung cancer in humans (group A carcinogen). Secondhand smoke is estimated by the agency to cause approximately 3,000 lung cancer deaths in nonsmokers each year (900). Given the high proportion of individuals with psychiatric disorders who smoke, those who reside or attend treatment programs with large numbers of other smokers may be at increased risk from environmental tobacco smoke.

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b) Issues related to specific physical disorders

Cardiovascular disease, lung cancer, and chronic obstructive pulmonary disease are the most common causes of morbidity and mortality among smokers, making it important to screen smokers for the signs and symptoms of these conditions (751, 901). Among smokeless tobacco, cigar, and pipe users, mouth and upper airway cancers are the most common causes of tobacco-induced mortality, and users of these forms of tobacco should be screened for the presence of these diseases (751, 901).

With smoking-related physical disorders, the duration of smoking abstinence is directly related to decreases in risk within 5 years of cessation (902–906). Smoking cessation also leads to an improved quality of life. Because medical hospitalization, cancer diagnosis, impending surgery, or exacerbation of cardiorespiratory symptoms may motivate individuals to consider smoking cessation, treatment for nicotine dependence is particularly important at these junctures. Screening for other substance use is also indicated, as smokers with pulmonary problems may be highly dependent and have a comorbid alcohol use disorder.

In general, the treatments for nicotine dependence that are recommended for use in the general population are effective in patients with co-occurring general medical conditions. NRTs decrease acute symptoms of nicotine withdrawal and increase smoking cessation rates (839, 907–912) without appearing to have any increased risk of adverse outcomes (836, 876, 913–916). Bupropion also appears to be safe as well as effective in individuals with cardiovascular (917) and pulmonary disease (918). Behavioral interventions improve smoking cessation rates when administered alone (875, 919, 920), as a package of several behavioral interventions (836, 875, 920, 921), or in combination with an NRT (908, 911, 912); they appear particularly useful when delivered in more intensive formats (855, 875, 920) or in conjunction with a program of smoking cessation aftercare (836, 875, 920, 921).

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4. Pregnancy

Pregnant women who smoke pose an immediate and considerable challenge, given the risks of smoking to the fetus (574, 922–928). Screening patients for their smoking status during pregnancy is essential, and biochemical measures may be more accurate than self-report measures in identifying those in need of intervention (929). The primary risk of smoking during pregnancy appears to be low-birth-weight infants. If a woman quits smoking by her third trimester, the risk of giving birth to a low-birth-weight infant is no greater than the risk to a nonsmoker (930–935).

There is good evidence that physician counseling about smoking during pregnancy is effective (936, 937). In addition, behavioral interventions may be preferred by many women (938, 939); thus, these interventions should be considered first-line treatments for pregnant smokers (939).

The evidence is mixed on the ability of NRTs to augment rates of smoking cessation in pregnant women compared with behavioral interventions alone (940, 941). Although there appears to be no increased risk for NRTs in pregnancy (930, 938), this has not been well studied. Nevertheless, the consensus suggests that any increase in risk that might occur with NRTs is likely to be less than the risk of ongoing smoking (942, 943). Intermittent forms of NRTs may be preferred over the nicotine patch as the former minimize nicotine exposure to the fetus (930). Although there are no reports on the teratogenicity of bupropion, the decision to treat a pregnant woman with bupropion should include consideration of the potential benefits and risks to the woman and the fetus.

Regardless of the form of treatment used to augment smoking cessation in pregnant women, postpartum relapse rates are high (738, 929, 944, 945), suggesting a need for additional efforts at relapse prevention.

Table Reference Number
Table 4. Fagerström Test for Nicotine Dependence

References

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