Cigarette smoking is rampant among psychiatric patients, and psychiatrists are, by and large, doing nothing about it.
One survey found the prevalence of smoking among individuals with psychiatric disorders to be 41%--nearly twice the general rate (Am. J. Addict. 2005;14:106-23). Other estimates are higher, with some suggesting that the psychiatric population accounts for nearly half of all cigarettes smoked in the United States.
At the same time, apparently less than 2% of patients who smoke receive tobacco counseling from their psychiatrists (Am. J. Addict. 2005;14:441-54).
"Typically, psychiatrists haven't accepted that smoking cessation is within the scope of their practice," said Dr. Jill M. Williams, director of mental health and tobacco services at the Robert Wood Johnson Medical School, Piscataway, N.J. "They're not trained to provide treatment for nicotine dependence."
Yet, they are well suited for this role. Psychiatrists can tailor smoking interventions to patients' needs, address changes in symptoms, and adjust psychotropic dosages when appropriate. And they can get results.
"Everyone assumes that it's harder for people with mental illness to quit, but we find that when treatment is optimized, the rate is the same as for others," said Dr. Tony P. George, professor of psychiatry and chair of addiction psychiatry at the University of Toronto.
The key to success is for "the psychiatrist to convey the impression that patients can quit if they want to," he said. "Ninety percent of the barrier is that psychiatrists don't think they can."
Treatment should have a behavioral component, but for the psychiatric population, "aggressive pharmacotherapy" plays a central role, Dr. George said.
Combinations of the agents approved for smoking cessation--bupropion (Zyban) and nicotine replacement therapy (NRT) in its various forms--are common. (A third drug, varenicline [Chantix], became available in late July). "Bupropion and NRT are comparably effective, so we often let patient preference guide the choice between them," Dr. Williams said.
She frequently uses NRT at a higher than approved dosage, particularly for patients who smoke more than a pack a day. A typical treatment plan might involve the full-strength (21-mg) patch, supplemented with a nicotine inhaler or gum used hourly, not as needed. "The patient can take more when he experiences craving or withdrawal," she said.
"We've had particular success with the nasal spray for patients with schizophrenia. It provides the highest blood level, which they need," Dr. Williams noted.
Smoking is most prevalent in schizophrenia (80% of patients in some estimates), and this has been the area of most research.
Quitting does not appear to exacerbate positive symptoms, but it may transiently disrupt cognitive function, Dr. George said. (It has been suggested that nicotine improves working memory and attention in schizophrenia patients via stimulation of the nicotinic acetylcholine receptor.)
Rather than combining NRT forms for high nicotine blood levels, Dr. George emphasizes polypharmacy. His recent study found that adding bupropion quadrupled nicotine patch quit rates in schizophrenia patients from 7% to 30%. Six months after the 10-week treatment period, 20% of the combined-treatment group was still abstinent, compared with 0% of nicotine-placebo controls.
Experimental strategies combining NRT with agents that mimic nicotine's psychoactive effects appears promising, Dr. George said. Atomoxetine (Strattera) "specifically targets dopamine deficiency in the frontal cortex" and may be useful in depression and bipolar disorder. …