Let’s Talk About Tobacco Use

Throughout residency we are trained to manage patients with unipolar depression on antidepressants, titrate mood stabilizers for those with bipolar disorders, and choose the right antipsychotic for schizophrenia-spectrum conditions. We refer patients with opioid or alcohol use to substance use treatment and prescribe sleeping aids to manage insomnia. What about patients with nicotine use disorder? As residents, we learn to engage patients in a motivational discussion about weighing harms and benefits of smoking; however, when it comes to offering FDA-approved pharmaceuticals to aid in their quit attempts, we sometimes fall short.

Almost half of our patients with mental illness smoke. According to the Centers for Disease Control and Prevention, these patients die five years sooner from heart and lung diseases and cancers related to smoking. Unfortunately, without adequate treatment, patients who smoke cigarettes have difficulty quitting and often turn to alternatives such as electronic cigarettes and vaping devices despite a paucity of evidence regarding their long-term consequences and efficacy for smoking cessation. It is well established that despite similar motivation, patients with mental illness are less likely to quit and more likely to relapse compared with the general population. It is apparent that these individuals warrant more than just counseling.

Having a passion to study addictive disorders, we asked our clinic patients about their tobacco use and how their tobacco use impacts their lives. We also saw how patients’ psychiatric conditions are impacted by their tobacco use. Nicotine use can worsen psychiatric conditions such as anxiety and insomnia, and for those who stopped using other substances, it can contribute to relapse.

During our residency, we have observed that medications for smoking cessation are underprescribed. At the beginning of residency, we learned about the black-box label for neuropsychiatric side effects (such as increased aggression and suicidality) associated with varenicline and bupropion. We would also hear about how, in clinical practice, some experienced senior physicians have seen individuals whose depression, irritability, or aggression has worsened upon having been placed on these medications by their primary care physician. All this translated into hesitancy in even considering discussing such medication options with patients.

In light of recent trials that resulted in the FDA removal of the black-box label, over the past year we started several of our stable psychiatric patients on varenicline or bupropion along with brief counseling at follow-up visits. As a precaution, we scheduled more frequent follow-ups compared with other patients being treated for the same condition; however, adverse side effects were not reported.

Before initiating medication for smoking cessation, we asked patients to set a target quit date (TQD) around a time with no anticipated stressors (for example, not around holidays or special events), and around a time with a lot of social support. The medications helped with impulse control and craving reduction while the brief counseling offered during office visits provided reassurance, coping skills strategies, and guidance on long-term abstinence. The outcomes have been astonishing—patients’ psychiatric conditions are better controlled despite no regimen changes, they are able to engage more in their medical care, and those who had other comorbid substance use problems were able to reduce and even cease use.

Tobacco use is the number one cause of preventable death among our patients. Most patients attempt to quit unaided, but the data strongly support pairing behavioral support with FDA-approved cessation medications for patients who want to quit. As trainees, we need to familiarize ourselves with the most effective cessation treatments and offer them to all suitable smokers. ■