Mr. V, age 49, has stable but symptomatic schizophrenia and a 33-year cigarette smoking history. He is very concerned because his primary care physician told him he has 2 serious smoking-related health problems: diabetes and hypertension. He tried a smoking cessation program for the general public, but it was a poor fit because of his schizophrenia symptoms.
Despite adhering to his medications (ziprasidone, 20 mg hs; perphenazine, 8 mg hs; lorazepam, 1 mg hs; zonisamide, 200 mg/d, and benztropine mesylate, 2 mg hs), Mr. V has residual auditory hallucinations, paranoid ideation, and impaired concentration and attention. He smokes approximately 1.5 packs per day, particularly when very ill, to alleviate chronic boredom, and to diminish distress from the hallucinations. All of his friends smoke, and they do not support his attempts to quit.
Successfully treating nicotine dependence can seem a formidable challenge in patients with schizophrenia:
* 72% to 90% smoke cigarettes, compared with 21% of the general population1 (Box, page 66). (2-12)
* They tend to smoke heavily, spending about one-third of their incomes on cigarettes. (13)
* Their negative symptoms (such as apathy), positive symptoms (such as disorganized thinking), and cognitive impairment can reduce motivation to quit and adhere to a smoking cessation strategy.
* Sociologic and physiologic aspects of schizophrenia reinforce their smoking habit (Table 1, page 69). (9,12,14-17)
Even so, smokers with schizophrenia can be highly motivated and persistent in attempting to quit. (18) Promising results have been reported in trials when psychopharmacologic treatments are combined with cognitive and behavioral interventions.
This article reviews these empiric studies and suggests practical ways for clinicians to create smoking cessation and relapse prevention plans for individuals with schizophrenia.
Clinical trials of smoking cessation
Inadequate interventions. Conventional regimens--consisting of 8 to 12 weeks with sustained-release bupropion or nicotine replacement therapy (NRT) added to supportive or cognitive-behavioral therapy (CBT) (19)--are well-tolerated by patients with schizophrenia but only modestly effective. CBT alone (or with placebo) has not been effective for smoking cessation in schizophrenia. In clinical trials, abstinence rates have been:
* 4% to 19% after 3 to 6 months with bupropion or NRT and CBT
* [less than or equal to]6% with placebo and CBT. (20-23)
Multifaceted interventions. High-dose NRT patch treatment (2 patches at a time) has not consistently shown additional benefits compared with single-patch treatment. (24,25) However, combining short-acting NRT (gum, lozenge, inhaler, or nasal spray) with a long-acting NRT preparation (transdermal patch) is well-tolerated and has been shown to improve sustained abstinence rates (26) (Table 2, page 70).
In a double-blind, placebo-controlled trial, (27) 51 smokers with schizophrenia were randomly assigned to receive combination NRT (21-mg NRT patch plus [less than or equal to]18 mg/d NRT polacrilex gum prn) added to bupropion SR, 150 mg bid, or placebo. Smoking cessation--defined as quitting on the assigned date and maintaining continuous abstinence for 4 weeks (measured by expired air carbon monoxide <9 ppm and self-report of abstinence at weekly visits)--was achieved by:
* 52% of those receiving bupropion and dual NRT
* 19% who received placebo and the 2 forms of NRT.
Preventing relapse. Relapse is common among all smokers but especially in those with schizophrenia. In clinical trials, 70% to 83% of smokers with schizophrenia who attained abstinence relapsed to smoking within 6 to 12 months of stopping nicotine dependence treatment. (21,22,27,28)
In one clinical trial, >50% of patients achieved 4 weeks of continuous abstinence on a regimen of bupropion SR, 150 mg bid; nicotine patch (21 mg/d); and as-needed nicotine gum ([less than or equal to]18 mg/d). …