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Clinical Crossroads
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February 4, 2009

A 51-Year-Old Woman With Bipolar Disorder Who Wants to Quit Smoking

Author Affiliations

Author Affiliation: Dr Schroeder is Distinguished Professor of Health and Health Care, Department of Medicine, University of California, San Francisco. He is Director, Smoking Cessation Leadership Center, University of California, San Francisco.

JAMA. 2009;301(5):522-531. doi:10.1001/jama.281.16.1531

Smoking among patients with mental illness is a major and underappreciated public health problem. The case of Ms G, a 51-year-old woman with bipolar disorder who wishes to quit smoking, illustrates the importance and feasibility of smoking cessation in patients with psychiatric disorders. Persons with chronic mental illness and/or substance abuse constitute 22% of the US population yet are estimated to consume 44% of cigarettes. As many as 200 000 of the 435 000 annual deaths related to smoking in the United States are estimated to occur in this population. On average, patients with mental illness die 25 years earlier than the general population, and smoking is a major contributor to these premature deaths. In the past, mental health clinicians have tended not to address smoking cessation with their patients, but increasing evidence suggests that such reticence is unwarranted, as smoking cessation in this population is feasible. The approach to cessation should include standard interventions of counseling and pharmacotherapy, for which substantial evidence of efficacy exists in patients with and without mental illness. If patients with mental illness are to achieve wellness, smoking cessation must be an integral component of their treatment regimen.

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    2 Comments for this article
    Nicotine Dependence Treatment Plan for Patient with Bipolar Disorder
    Katharine M. Patsakham, MPH | University of North Carolina at Chapel Hill School of Medicine
    Smoking rates among those suffering from mental illness or substance abuse are two to four times higher than in the general population, ranging from 50-90%.1 These individuals consume 44% of the cigarettes smoked in the United States.2 People with mental illness not only have higher rates of smoking but they smoke more cigarettes per day and take in more nicotine per cigarette, leading to higher levels of dependence.3 Tobacco use is a significant cause of morbidity and mortality in this population. People with serious mental illness die on average 25 years younger than the general population, with the cause of death often linked to smoking.4 Most published research focuses on the prevalence, predictors, and negative consequences of smoking in persons with bipolar disorder rather than effective cessation treatment. National data suggest that, among those who suffer from bipolar disorder, 61% are current smokers.2 Smoking is associated with more severe forms of bipolar disorder, concurrent alcohol and drug use, and co-morbid psychiatric disorders.5
    In general, the literature suggests that smoking cessation, when undertaken with appropriate support, does not exacerbate mental illness. In some cases, quitters experience lower levels of affective distress than those who continue to smoke.6 According to clinical practice guidelines, the most effective treatment for nicotine dependence includes both medication and counseling.7 Among all smokers, the combination of a long- acting nicotine replacement therapy (NRT) patch (to provide steady state nicotine levels) and short-acting NRT gum or nasal spray (to treat breakthrough cravings) is associated with the highest abstinence rates.7 Research on schizophrenia suggests that people with mental illness require a more flexible and gradual approach to quitting and that nicotine replacement therapy may be especially beneficial for this population.8-10 Because they smoke more, individuals with mental illness may require higher doses of cessation medication for longer periods of time.8 In addition, smoking increases the metabolism of many psychiatric drugs; smokers may need up to twice as much medication as non-smokers and may require dose adjustments when quitting.3
    In Ms. G's own words, the statement, "I am committed to stopping smoking" is immediately followed by, "I guess I'm not full-hearted into quitting." I would begin by exploring this ambivalence in more detail. What does she like about smoking? What good things might happen if she quits? What do those four cigarettes represent for her? After assessing her goals and current readiness to change, I would discuss the possibility of discontinuing Chantix in favor of NRT - using the patch to maintain baseline levels of nicotine in combination with the lozenge to replace the remaining four cigarettes. Ms. G's past experience indicates that continued participation in regular individual and group support would also be beneficial.
    Ms. G. may need medication and support for an extended period of time. An effective treatment plan will take into account the fact that periods of unstable mood in the future will place her at risk for relapse. I would encourage her to view quitting as a process and congratulate her on her progress so far.
    No relevant financial interests.
    1. Williams JM, Ziedonis D. Addressing tobacco among individuals with a mental illness or an addiction. Addictive Behaviors. 2004;29(6):1067-83.
    2. Lasser K, Boyd JW, Woolhandler S, et al. Smoking and mental illness: A population-based prevalence study. JAMA. 284(20):2606-10.
    3. Ziedonis D, Williams JM, Smelson D. Serious mental illness and tobacco addiction: a model program to address this common but neglected issue. Am. J. Med. Sci. 2003;326(4):223-30.
    4. National Association of State Mental Health Program Directors. Morbidity and Mortality in People with Serious Mental Illness. Thirteenth in a Series of Technical Reports.. Alexandria, Virginia; 2006.
    5. Waxmonsky JA, Thomas MR, Miklowitz DJ, et al. Prevalence and correlates of tobacco use in bipolar disorder: data from the first 2000 participants in the Systematic Treatment Enhancement Program. Gen Hosp Psychiatry. 27(5):321-8.
    6. Currie S, Karltyn J, Lussier D, et al. Outcome from a Community- based Smoking Cessation Program for Persons with Serious Mental Illness. Community Mental Health Journal. 2008;44(3):187-194.
    7. Fiore M, Jaen C, Baker T. Treating Tobacco Use and Dependence. 2008 Update. . Rockville, MD: U.S. Department of Health and Human Services. Public Health Service; 2008.
    8. Williams JM, Ziedonis DM, Foulds J. A case series of nicotine nasal spray in the treatment of tobacco dependence among patients with schizophrenia. Psychiatric Services (Washington, D.C.). 2004;55(9):1064-6.
    9. Williams JM, Foulds J. Successful Tobacco Dependence Treatment in Schizophrenia. Am J Psychiatry. 2007;164(2):222-227.
    10. McChargue DE, Gulliver SB, Hitsman B. Would smokers with schizophrenia benefit from a more flexible approach to smoking treatment? Addiction. 2002;97(7):785-93; discussion 795-800.
    On The Brink of Quitting
    One good thing about this profile is the willingness of the case patient to quit. Ms G is typical of many smokers in having tried (1), and has done more than average in using more than one cessation regimen in those attempts. Although smoking is twice as common in persons with mental illness than in the general US population, quit rates in persons like Ms G who are abstinent from alcohol and illicit drugs approximate that of smokers without mental illness (2). Her chances of quitting are higher than for most smokers, considering that she has cut her cigarette consumption by more than 50% and presently smokes fewer than 15 cigarettes a day (3). I currently do not know of studies documenting quit rates on the combination of varenicline and bupropion, but I believe Ms G is close to successful smoking cessation. References
    1. Cigarette smoking among adults--United States, 2007. MMWR Morb Mortal Wkly Rep. Nov 14 2008;57(45):1221-1226.
    2. Lasser K, Boyd JW, Woolhandler S, Himmelstein DU, McCormick D, Bor DH. Smoking and Mental Illness: A Population-Based Prevalence Study. JAMA. November 22 2000;284(20):2606-2610.
    3. Hyland A, Levy DT, Rezaishiraz H, et al. Reduction in amount smoked predicts future cessation. Psychol Addict Behav. Jun 2005;19(2):221 -225.