People with mental illness
Smoking in people with mental health problems is common. The smoking rate of the Australian population is just over 15%,1 but for people with a mental health problem the rate is about 32%.22 In some cases, such as for people with schizophrenia, the rate is up to 66%.192
People with mental illness such as schizophrenia, depression, bipolar disorder and anxiety often experience physical, financial and social disadvantages because of their illness.193,194 There is evidence that people with mental illness are just as motivated to quit as the general population.195 Actively encouraging and assisting smoking reduction and cessation are important to improve their quality of life. Tobacco smoking can also interfere with the medications taken for schizophrenia and depression, and the doses of some psychotropic medications may need to be decreased.
Treating tobacco dependence is a worthwhile intervention for people with severe mental illness and may be just as effective as for the general population. However, it should be realised that cessation rates are generally lower in this group for any given level of assistance. A mix of face-to-face help augmented by Quitline calls is as effective as intensive face-to-face help. In people with stable psychiatric conditions it should not worsen mental health.194,196
In fact, smoking cessation is associated with reduced depression, anxiety and stress together with improved mood. This is true in those with and without a diagnosed psychiatric disorder.197
Health professionals should offer people with a mental illness smoking cessation interventions that have been shown to be effective in the general population.8 Mental illness is not a contraindication to stopping smoking but the illness and its treatment need to be monitored carefully during smoking cessation.198–200
Patients quitting smoking with any method are at some risk of increased psychological stress during the quitting process, but the risk is higher for those with a history of mental illness. Clinicians should monitor patients with mental illness more closely and advise prompt reporting of adverse events.
Recommended smoking cessation treatment
- Intensive smoking cessation counselling and close follow-up are important in this group.
- NRT is safe and effective for people with a mental illness.
- Consultation with a psychiatrist may be considered for advice on use of medicines for smoking cessation in people with significant mental illness.
- Bupropion may not be suitable for people with a history of seizures, people with a history of anorexia or bulimia and people using other antidepressants. Caution is needed if there is concomitant use of bupropion with drugs such as tricyclic antidepressants and selective serotonin reuptake inhibitors. These drugs should be initiated at the lower end of the dosage range while a smoker is taking bupropion. In the more common situation that bupropion is initiated for a person already taking such antidepressants then the dose of tricyclic, or selective serotonin reuptake inhibitor, may need to be decreased. Bupropion should not be used in patients taking monoamine oxidase inhibitors (MAOIs) including moclobemide. A 14-day washout is recommended between completing MAOIs and starting bupropion. Consultation with a psychiatrist may be considered for advice on co-prescribing bupropion with other antidepressants.
- There is increasing evidence of the safety and efficacy of varenicline in people with significant psychiatric illness. Varenicline helps with withdrawal symptoms and takes away the pleasure of smoking. There have been reports of depressed mood, suicidal ideation and changes in emotion and behaviour using this product, though a meta-analysis of data from 17 clinical trials found no association.128 Several randomised trials have shown varenicline to be safe and effective in depression and schizophrenia.124–126 Therefore varenicline can be used in this population but prescribers should ask patients to report any mood or behaviour changes. Patients should be advised to stop taking varenicline at the first sign of any of these symptoms.
- Australian Institute of Health and Welfare. 2010 National Drug Strategy Household Survey report. Drug statistics series no. 25. Cat. no. PHE 145. Canberra: AIHW, 2011. Available at http://www.aihw.gov.au/WorkArea/DownloadAsset.aspx?id=10737421314 [accessed 12 August 2011].
- Zwar N, Richmond R, Borland R, et al. Smoking cessation pharmacotherapy: an update for health professionals (updated 2009). Melbourne: The Royal Australian College of General Practitioners, 2009.
- Australian Institute of Health and Welfare. 2007 National Drug Strategy Household Survey: first results. Drug statistics series no. 20. Cat. no. PHE 98. Canberra: AIHW, 2008. Available at www.aihw.gov.au/publication-detail/?id=6442468084 [accessed 27 March 2011].
- Anthenelli RM, Morris C, Ramey TS, Dubrava SJ, Tsilkos K, Russ C, Yunis C. Effects of varenicline on smoking cessation in adults with stably treated current or past major depression: a randomized trial. Ann Intern Med 2013 159(6):390−400.
- Williams JM, Anthenelli RM, Morris CD, Treadow J, Thompson JR, Yunis C, George TP. A randomized, double-blind, placebo-controlled study evaluating the safety and efficacy of varenicline for smoking cessation in patients with schizophrenia or schizoaffective disorder. J Clin Psychiatry 2012;73(5):654−60.
- Pachas GN, Cather C, Pratt SA, et al. Varenicline for smoking cessation in schizophrenia: safety and effectiveness in a 12-week, open-label trial. J Dual Diagn 2012;8(2):117−125.
- Gibbons RD, Mann JJ. Varenicline, smoking cessation, and neuropsychiatric adverse events. Am J Psychiatry. 2013 Dec 1;170(12):1460-7.
- Cooper J1, Mancuso SG, Borland R, Slade T, Galletly C, Castle D. Tobacco smoking among people living with a psychotic illness: the second Australian Survey of Psychosis. Aust N Z J Psychiatry 2012 Sep;46(9):851−63.
- Strasser K, Moeller-Saxone K, Meadows G, Stanton J, Kee P. Smoking cessation in schizophrenia. General practice guidelines. Aust Fam Physician 2002;31:21–4.
- Tsoi DT, Porwal M, Webster AC. Interventions for smoking cessation and reduction in individuals with schizophrenia. Cochrane Database Syst Rev 2010, Issue 6. Art. no. CD007253.
- Siru H, Hulse GK, Tait RJ. Assessing motivation to quit smoking in people with mental illness: a review. Addiction 2009; 104: 719–33.
- Banham L, Gilbody S. Smoking cessation in severe mental illness: what works? Addiction 2010;105:1176–89.
- Taylor G1, McNeill A, Girling A, Farley A, Lindson-Hawley N, Aveyard P, Change in mental health after smoking cessation: systematic review and meta-analysis. BMJ. 2014 Feb 13;348:g1151. doi: 10.1136/bmj.g1151.
- Weiner E, Buchholz A, Coffay A, et al. Varenicline for smoking cessation in people with schizophrenia: a double blind randomized pilot study. Schizophr Res 2011 Mar 2. [Epub ahead of print].
- Baker A, Richmond R, Haile M, et al. A randomized controlled trial of a smoking cessation intervention among people with a psychotic disorder. Am J Psychiatry 2006;163:1934–42.
- Baker A, Richmond R, Lewing TJ, Kay- Lambkin F. Cigarette smoking and psychosis: naturalistic follow up 4 years after an intervention trial. Aust NZ J Psychiatry 2010;44:342–50.