Tobacco dependence in mental health disorders

1. Tobacco Dependence in
Mental Health disorders

2. When is it Addiction?
Three or more of the following:
Preoccupation with getting tobacco
Compulsive use
Difficulty with controlling intake
Persistent, even with health problems
Relapse
Tolerance
Withdrawal
How long does it take to become dependent?
Can be after the first cigarette!
References: World Health Organization
Diagnostic and Statistical Manual - IV (DSM-IV)

3. What Initiates Tobacco Use?
Self
Actualization Being Need
Esteem Needs
Social Needs
Deficit Needs
Security & Safety Needs
Physiological Needs
A. H. Maslow. A Theory of Human Motivation. Psychological Review, 50, 370-396. (1943)

4. Addiction via smoking
cigarettes have additives that
cause addiction
sensory cues (heat, sight, and
smell)
smokers have greater number of
nicotinic receptors
inhalation from cigarettes causes
nicotine to cross blood brain
barrier more rapidly

5. Stages of Change Model
Prochaska, J. & DiClemente, C. (1983). Stages and processes of self-change in
smoking: Toward an integrative model of change. Journal of Consulting and Clinical
Psychology, 51, 390-395.

6. Interventions
Behavioral Pharmacologic
•Self-help materials
•Brief Advice
•Counseling
•Exercise
•Nicotine-replacement therapy
•Bupropion
•Varenicline

7. Multi-Component Interventions
Increase Long-Term Quit Rates
No
Therapy
Brief
Advice
Behavioral
Therapy
Placebo/
No Medication
5% 10% 15%
First-Line
Medication
10% 20% 30%
Source: Hughes JR. CA Cancer J Clin 2000;50:147.

8. The prevalence of tobacco use in people with MHA
disorders is 2 to 4 times higher than in the general
population (lesser et at, 2008).
The more important that many of them were unable to
quit smoking.
Other studies have found that people with MHA
disorders are at higher risk for developing many
tobacco-related diseases, including cardiovascular
and respiratory disease, and various cancers,
compared with the general population (Hennekens et al,
2005).

9. Why?
Several explanations have been proposed for the high
prevalence of smoking in people with MHA disorders
(kalman et al,2005).
1.There may be intrinsic factors (for example, shared
genes) that predispose people with MHA to initiation
and maintenance of smoking behaviours.
2.Nicotine may be used by MHA patients to self
medicate psychiatric symptoms and psychotropic drug
side effects.

10. Cont...
3.There may be common social and environmental
determinants of this comorbidity (for example, easy
access and availability, poverty, environmental
stressor).
4. Nicotine administration through cigarette smoking
may modulate several neurotransmitter systems (for
example, DA, Glu, and GABA) thought to be involved
in the pathogenes is of MHA disorders.
5. Psychological mechinsms: distress tolerance,
negative affect and anxiety sensitivity and personality
traits.

11. Treating Tobacco Use and Dependance
in psychiatric patients.

12. Nicotine metabolism is mediated primarily by the
cytochrome P450 1A2 (CYP1A2) and by CYP2A6.
Since many psychiatric drugs, including diazepam,
haloperidol, olanzapine, clozapine, fluphenazine, and
mirtazapine, are also metabolized through CYP1A2
induction, smoking can lower their therapeutic blood
levels and decrease their effectiveness.
Heavy smokers would require a 50–100% increase in
olanzapine dose compared with nonsmokers to
achieve the same therapeutic level (wu et al,2009).

13. Cont...
Smoking cessation leads to increased plasma
concentrations with increased risks of adverse effects,
creating a requirement for close drug dose monitoring
in smokers during smoking cessation.
Conversely, antipsychotic medications may
differentially impact an individual’s smoking status; for
example, patients with schizophrenia were found to
smoke more after initiation of haloperidol treatment
and less when switched from haloperidol to clozapine.

14. Cont...
Other atypical antipsychotic medications, for example
olanzapine and risperidone, can also reduce smoking
rates and this effect may be attributable to increased
cortical dopamine release, as well as enhanced
prefrontal NMDA receptor-mediated transmission
(Jardemark et al,2005).
It had been thought that smoking cessation may lead
to an exacerbation of psychiatric symptomatology and
an erroneous belief that smokers with comorbid
psychiatric conditions are not motivated to quit
smoking.

15. Cont...
Fortunately, the preponderance of evidence suggests
that psychiatric symptoms typically do not worsen and,
in fact, may even improve following abstinence from
tobacco (hitsman et al, 2009).
1-Schizophrenia: Patients with schizophrenia are the
group with the highest rates of tobacco use (70-85%),
and for whom there has been considerable interest in
identifying effective smoking cessations interventions .

16. Cont...
Between the recommended pharmacotherapies for
treating nicotine dependence, bupropion has been
demonstrated to have the greatest benefits for these
patient population (banham et al, 2010).
The same meta-analysis found there was no evidence
of benefit of NRT in smokers with schizophrenia.

17. Cont...
2-mood and anxiety disorders: About 45% of patients
with major depressive disorder smoke. At present, the
approach with the most empirical support, is the inclusion
of cognitive behavioral therapy focusing on mood
management as part of the cessation intervention.
With regard to pharmacotherapy, there is insufficient
evidence to suggest that a particular type of medication is
more effective for patients with comorbid depression.

18. Cont...
Despite the high rates of smoking among those with
anxiety disorders, surprisingly little is known the best way
to approach treatment for this patient population. Results
for one small-scale study suggest that bupropion may
increase cessation rates among patients with PTSD
(Hertzberg et al,2001).
3-ADHD: Bupropion has shown efficacy in treating dults
with ADHD and has also been approved by the Food and
Drug Administration as an aid to smoking cessation
(Wilens et al, 2006). Novel cholinergic agents have also
shown promise in treating adults with ADHD (Vanable et
al,2003).

19. Cont...
Non pharmacological approaches to treating ADHD
might also be useful in facilitating smoking cessation.
Emerging work shows promise for the use of ognitive-behavioral
treatment of adults with ADHD.

20. It is not all or non?
Smoking cessation treatments in which treatment
participation and smoking reduction have been
targeted outcomes, with abstinence as the implicit end
point, have tended to be more successful in achieving
substantial smoking reduction and eventual
abstinence in MHA smokers (Gallagher et al,2007).

21. Tobacco Policy for Inpatient
Psychiatric Units
Smokers with MHA disorders often do not have access to
supports that help to promote quitting and sustained
smoking abstinence. The psychiatric treatment setting,
especially inpatient units, can serve an important role in
promoting smoking cessation.
Concern that restricting smoking may exacerbate clinical
status has contributed to a reluctance to enforce smoking
bans despite evidence that smokers, compared with
nonsmokers, present with more severe symptomatology.
Most studies report positive outcomes following inpatient
bans (Lawns et al, 2005).

22. THANK YOU