Smoking Cessation for Patients Called an Urgent Priority

A mark of sophistication and cool in an earlier age, smoking has diminished dramatically among the general population—in social status and prevalence—arguably one of the most profound social changes in decades.

But among people with mental illness, and especially those who are seriously mentally ill (SMI), smoking and tobacco addiction remains stubbornly persistent, 50 years after the landmark surgeon general’s report on smoking and health.

Psychiatrist Jill Williams, M.D., is one of a handful of psychiatrists who are championing the cause of smoking cessation for this population. She began work in the field as a clinical researcher, conducting clinical trials and human laboratory studies to improve smoking-cessation rates in smokers with a serious mental illness, particularly schizophrenia; more recently she has become convinced of the need for measures such as public-health messages tailored to the SMI population, as well as tobacco control policies and advocacy.

“Although the smoking prevalence rate has dropped from 50 percent to 20 percent in recent decades, smokers with behavioral health comorbidity have been left behind in these efforts, making them overrepresented among the remaining smokers in the United States,” Williams told Psychiatric News. “Estimates are that smokers with mental illness smoke at two to three times the rates seen in the general population. Smokers with mental illness have ample evidence of tobacco-use consequences, including excess morbidity, early mortality, increased financial burden, and reduced quality of life. In addition, smokers with mental illness have reduced access to tobacco-dependence treatment across the health care spectrum.”

Despite evidence that a variety of treatment options are effective in smoking cessation, clinicians involved in the movement toward integrated care have yet to seize upon this issue in a major way to improve the overall health status of mentally ill individuals who smoke.

“As I travel the country and talk to people involved in integrated care, I am impressed at the efforts people are making to address cardiovascular risk, especially through exercise and weight management,” she said. “But I have not seen the same level of commitment to smoking cessation.”

But the idea is gaining traction. Lori Raney, M.D., chair of APA’s Work Group on Integrated Care, said there has been a remarkable growth in literature recently about smoking and mental illness and about the effectiveness of treatment (see article below).

She said smoking cessation is taught as part of the “Primary Care Skills for Psychiatrists” course already offered at APA’s annual meeting and Institute on Psychiatric Services; she would now like to see tobacco cessation as the subject of a lecture at the institute.

“Psychiatrists can and should take a leadership position in this effort in public mental health settings, private practice, inpatient psychiatric units, and inpatient medical-surgical units,” Raney told Psychiatric News. “It is clearly within our scope of expertise, and nicotine dependence is, after all, a DSM-5 diagnosis.

“If we learn how to treat tobacco dependence and become advocates for such treatment, we add value to integrated health care networks and to the larger health care system,” Raney said. “We elevate the importance of psychiatrists while helping to achieve the goals of the ‘Triple Aim’—to improve outcomes, contain costs, and enhance patient satisfaction.”

At a meeting of the Academy of Psychosomatic Medicine in November 2013, Joseph Cerimele, M.D., a senior fellow at the University of Washington, presented a lecture on smoking and serious mental illness. He reported data from the Centers for Disease Control and Prevention showing that from 2009 to 2011, individuals with mental illness were more likely to smoke, smoked more cigarettes daily, and had lower successful quit rates than the general population.

Importantly, Cerimele also presented evidence that despite some anecdotal case reports of neuropsychiatric side effects associated with use of varenicline, published research continues to indicate its safety and effectiveness for smoking cessation. He presented a report from the September 2013 Annals of Internal Medicine showing that varenicline resulted in improved continuous abstinence compared with placebo, with no worsening of depressive or anxiety symptoms.

“Treatment works,” Williams agreed. “There are clinical trials showing that medications and/or counseling in smokers with depression and schizophrenia are effective and well tolerated.”

So why has “kicking the habit” been so successful generally but lagged behind among the SMI population?

Williams said that she believes there is a prevalent notion among some mental health clinicians that smoking cessation is a task for primary care. More importantly, she said there has been a widespread belief that smoking cessation can make mental illness recur—or even that smoking may be palliative for patients with mental illness; some reports have shown that nicotine may improve some cognitive aspects of people with schizophrenia or attention-deficit disorder. But Williams countered that this cannot be a rationale for smoking when nicotine replacement medication is readily available.

Additionally, “smoking breaks” are an accepted part of the routine for patients at many psychiatric hospitals, and Williams said some privately owned institutions resist smoking bans for fear they may diminish attractiveness to patients.

At the public-health level, resources have not been allocated to smoking cessation among mentally ill individuals. “Just as there used to be a divide between addiction and mental health, there is a siloing of resources with regard to tobacco,” she said. “Public-health departments have directed all of their initiatives to primary care with very little outreach to behavioral health.”

For all of these reasons, Williams believes that advocacy for broad public policies aimed at creating a “culture change”—analogous to the change with regard to attitudes toward smoking that has occurred in the larger society—is vital.

“This issue is urgent,” she said. “We need a commitment to advocacy and public policy to help reduce morbidity and mortality associated with smoking among our patients.” ■

A primer on integrated care for clinicians and additional resources can be accessed at http://www.psychiatry.org/integratedcare.