People with mental health and addictive (MHA) disorders smoke at high rates and require tobacco treatment as a part of their comprehensive psychiatric care. Psychiatric care providers often do not address tobacco use among people with mental illness, possibly owing to the belief that their patients will not be able to quit successfully or that even short-term abstinence will adversely influence psychiatric status. Progress in the development of treatments has been slow in part because smokers with current MHA disorders have been excluded from most smoking cessation trials. There are several smoking cessation treatment options, including psychological and pharmacological interventions, that should be offered to people with an MHA disorder who smoke. Building motivation and readiness to quit smoking is a major challenge, and therefore motivational interventions are essential. We review the treatment options for people with tobacco dependence and MHA disorders, offer recommendations on tobacco assessment and tailored treatment strategies, and provide suggestions for future research. Treatment efficacy could be enhanced through promoting smoking reduction as an initial treatment goal, extending duration of treatment, and delivering it within an integrated care model that also aims to reduce the availability of tobacco in MHA treatment settings and in the community.
Can J Psychiatry. 2009;54(6):368-378.
* Tobacco treatment combining cognitive-behavioural therapies and motivational enhancement interventions tailored to the needs of smokers with MHA disorders, as well as pharmacotherapy integrated into ongoing psychiatric care, provides the best abstinence outcomes.
* Tobacco treatments do not appear to have an adverse effect on psychiatric symptoms. On the contrary, patients may demonstrate significantly improved clinical status following treatment regardless of abstinence status.
* Smoking reduction (reduction as the initial treatment goal), a chronic disease approach, and integrated care strategies have the potential to improve the efficacy of existing smoking treatment tailored to MHA smokers.
Key Words: tobacco dependence, mental health, addiction, smoking cessation, smoking reduction, pharmacotherapy, cognitive-behavioural treatment, tobacco ban
Abbreviations used in this article
BD bipolar disorder
CBT cognitive-behavioural therapy
CM contingency management
DSM Diagnostic and Statistical Manual of Mental Disorders
FTND Fagerstrom Test for Nicotine Dependence
MDD major depressive disorder
MET motivational enhancement therapy
MHA mental health and addictive
NRT nicotine replacement therapy
PTSD posttraumatic stress disorder
RCT randomized controlled trial
SUD substance use disorder
TD tobacco dependence
TNP transdermal nicotine patch
USPHS United States Public Health Service
Substantial progress has been achieved during the last decade in the treatment of tobacco use and dependence among people with MHA disorders. However, despite the steady increase in the efficacy of treatments for nonpsychiatric smokers, as well as tailored interventions for people with comorbid TD and MHA disorders, longer-term quit rates (more than 6 months) remain disappointingly low for MHA smokers, and significantly lower than the quit rates observed among nonpsychiatric smokers.1
We review our current understanding about treatment of tobacco use and TD in people with MHA disorders, and identify promising treatment strategies that could be integrated into current treatments to improve cessation outcomes in these populations. One factor associated with the slow progress in the treatment of TD is that smokers with current MHA disorders are often excluded from smoking cessation trials, especially those evaluating novel pharmacotherapies.2,3 Encouraging retention and abstinence results from the initial treatment studies,4-7 as well as the discussions of subsequent review papers,1,8-12 have helped to focus attention on this important comorbidity in MHA populations. …