As noted in the 2004 guideline, smoking cessation is a critical health challenge for individuals with schizophrenia. Smoking treatments include nicotine replacement therapies (NRTs), bupropion, and psychosocial approaches (88).

Recent studies have examined combined pharmacological and psychosocial approaches in individuals with schizophrenia. For example, Baker et al. (89) found higher abstinence rates among smokers with psychotic disorders who were enrolled in an 8-session behavioral/motivational enhancement intervention combined with NRT relative to those in routine care over a 12-month period. Several randomized, placebo-controlled trials suggest that bupropion (90), bupropion plus NRT (91,92), and bupropion plus a cognitive-behavioral intervention (93) significantly improve the likelihood of smoking reduction or smoking cessation among individuals with schizophrenia. However, the fact that these studies found significant rates of relapse following study termination suggests that smokers with schizophrenia may require more extended pharmacological treatment in combination with continuous and active support for smoking cessation. Bupropion is FDA approved for the treatment of smoking cessation and thus can be recommended as an intervention for smoking cessation for individuals with schizophrenia. Varenicline is also FDA approved for the treatment of smoking cessation but has not been studied in a randomized fashion among individuals with schizophrenia. With bupropion and varenicline treatment, a recent FDA boxed warning has highlighted a potential for serious neuropsychiatric symptoms, including changes in behavior, hostility, agitation, depressed mood, suicidal thoughts and behavior, and attempted suicide (94).

Research on psychosocial interventions suggests that smokers with schizophrenia will attend psychosocial smoking cessation programs, that interventions can have some benefit in terms of smoking reduction, and that, for those who attend, quitting is possible (89). Programs designed for individuals with schizophrenia may need to include extended outreach to improve treatment engagement and retention, training in coping skills that can be used to manage negative affect in place of smoking, and other strategies that can overcome some of the common barriers to smoking cessation found among this group of smokers.

Recent studies suggest that a motivational intervention designed for individuals with schizophrenia and substance use disorders may improve substance use and psychiatric outcomes for individuals with a dual diagnosis. Two recent studies found that brief interventions incorporating motivational and behavioral techniques to treat substance use disorders contributed to reductions in substance use among individuals with schizophrenia spectrum diagnoses (95,96). Specifically, Graeber et al. (95) found higher abstinence rates among individuals with schizophrenia and alcohol use disorders who were involved in a three-session motivational enhancement program relative to those involved in an educational intervention. Similarly, James et al. (96) found that individuals involved in a six-session, manualized group intervention with motivational enhancement and relapse prevention showed greater improvements in drug-related consequences and reductions in marijuana, alcohol, and polydrug use at follow-up relative to individuals who attended a one-session drug education class. Sigmon and Higgins (97) used a within-subjects reversal design to test the impact of a voucher-based contingent reinforcement intervention to reduce marijuana use in seven participants (86% having a schizophrenia diagnosis). Participants completed 4 weeks of baseline monitoring, during which they received $10 vouchers per urine specimen independent of result, followed by 12 weeks of intervention, during which they received $10 per urine specimen that was negative for marijuana, followed by another 4 weeks of baseline monitoring. The percentage of negative tests was significantly greater during the intervention weeks. However, two studies did not find that involvement in a substance use intervention contributed to lower rates of substance use (98,99). Although there is variability in research methodology and findings, motivational and behavioral interventions targeting substance use for individuals with dual diagnoses appear to be feasible and beneficial.