1. Why People with Mental Health Conditions Smoke So Much and What To Do About It John Hughes University of Vermont, USA john.hughes@uvm.edu

2. Disclosure I have received grants, consulting fees or speaking fees from most of the priviate companies, non-profits and governmental organizations prompting smoking cessation devices, medication and services.

3. Nicotine, The “Renaissance”Drug Relieves anxiety and depression Relieves anger Improves concentration Decreases hunger

4. What Are the Problems Facing 16 yr Olds? Controlling mood Controlling anger Concentrating Controlling weight

5. Occurs quickly after the behavior Frequent self-administration Effects occurs reliably No intoxication Requires few skills to obtain Nicotine Via Cigarettes is the Perfect Reward

6. No disorder43% Major depression38% Anxiety disorders33% Alcohol/Drug29% Schizophrenia27% Bipolar17% Lifetime Smoking Cessation Rates by Psychiatric Disorder (Lasser 99)

7. Attributable Deaths

8. Expenditures on Tobacco Smokers with schizophrenia spend 27% of income on tobacco Cf: In US, 20% spent on housing and 10% spent on food

9. Casual Flow of Depression and Smoking (Breslau 1991) Depression predicts progress to daily smoking OR = 3.0 Smoking predicts onset of depression OR = 1.9

10. Smokers with vs without Mental Health Conditions Fewer neversmokers (20% vs 55%) Fewer exsmokers (10% vs 25%) Fewer quit attempts (15% vs 45%) Less success when try to quit (10% vs 15%)

12. Ever Quit = Success/Quit Attempt x Number of Quit Attempts

13. The lower rate of lifetime cessation is as much due to fewer quit attempts as to less success on a given attempt.

14. Examples of How Smoking Interacts with Dx and Tx of Mental Health Disorders

15. Hints for Smoke-Free Facilities Explain rationale –to decrease second hand smoke –to decrease initiation or relapse among never or former smokers on ward –not to pressure you to quit Treat withdrawal with NRT Predicted disasters do not occur

16. Nicotine Withdrawal Anxiety Restlessness Irritability Difficulty concentrating Hunger/weight gain Insomnia Depressed mood Decreased heart rate

17. Overlap in Nicotine Withdrawal and Mental Health Diagnosis and Tx SymptomDiagnosis IrritabilityDrug withdrawal InsomniaSeveral disorders RestlessnessAkathesia Weight gainTCA side-effects

18. Smoking Abstinence Increases Drug Blood Levels  Fluphenazine  Fluvoxamine  Haloperidol  Imipramine  Oxazepam  Caffeine  Clomipramine  Clozaril  Clozapine  Doxepin

19. Blood Levels by Smoking Status Smokers Nonsmokers SmokersNonsmokers Clozaril Fluvoxamine

20. Mental Health Disorder General population Pre- contemplation 43%57% Contemplation38%33% Preparation19%10% Interest in Quitting Smoking

21. Interest in Quitting Smoking Among Those with Alcohol Problems (Hall, 09) 44% - 80% want to quit in near future 25% want to stop concurrent with stopping alcohol

22. Ever Quit = Number of Quit Attempts x Success/Quit Attempt

24. Lay Explanations of Behavior Change Cathartic event Sudden insight Large contingency Solid decision to change: “Just Do It”

28. Effect of Not Presenting Cue When MDs do not mention smoking, smokers conclude –My use is not that problematic –The MD does not think I can change

29. Tips for Treating Smoking in Those with Mental Health Conditions Keep smoking cessation on problem list Motivate every few months using personal risks and discussing barriers Let patient decide timing

30. Prompting Quit Attempts Best done when less symptomatic Set up as natural progression from conquering one problem to taking on another one Emphasize many quit without mental health conditions

31. Addressing Smoking in People with Mental Health Conditions 90% of effort is prompting quit attempt 90% of time not be successful 90% of time will take several prompts

32. Relapse Curve in Self-Quitters

33. Proven Treatments Behavioral Therapies –Quitlines –Groups – Individual Medications –Nicotine gum, inhaler, lozenge, patch, combinations –Bupropion –Varenicline

34. Behavioral Treatments Usually increase quitting by 1.5x Quitlines effective – but used by < 5% Group and individual effective but rarely available Internet and social media effective No recent progress in improving outcomes No reimbursement Few trained therapists

35. New Behavioral Treatments Mindfulness Acceptance Therapy Behavioral Activation Therapy Persistence Therapy Exposure Therapy

36. ORs for Effect of Proven Medications Nicotine gum1.7 Nicotine patch1.7 Nicotine inhaler2.1 Nicotine lozenge2.1 Combined NRTs2.4 OTC NRT2.0 Bupropion2.1 Varenicline2.8

37. Better Use of Treatment Combined patch + ad lib NRT or Varenicline is first line tx Pre-treatment Extended Treatment Continued use after a lapse

38. Other Medication Treatments Under Study Mouth spray Faster oral NRT Snus True nicotine inhalers Non-nicotine cigarettes Cytisine Sensory replacement Vaccine

39. Varenicline and Psychological Adverse Events Based on case reports Not found in meta-analysis of 39 trials Not found in five large real world data sets (total n > 55,000)

40. Types of Treatments Used No treatment63% OTC Medications25% Rx Medications8% Talking tx2% Internet2%

41. Incidence of Treatment Use Smoking25-35% Depression25-50% Alcoholism 10-12%

42. Percent of Quit Attempts That are Unplanned Larabie, 200552% West, 200049% Fergusen, 200940%

43. 2/3rds of Rxs for varenicline are patient initiated

44. Non-Cessation Indications Reduction as preliminary to abstinence Reduction to reduce harm Withdrawal relief during temporary abstinence

45. Reduction in Unmotivated Smokers No TxReductionMotivational Quit Attempt16%43%51% 6 Mo Quit4%18%23%

46. Reduce-to-Quit Gradual cessation is common (35-60% of attempts) RTQ approved in many European countries and Canada Unlikely to be approved in US anytime soon

47. Tips for Treating Smoking in People with Mental Health Conditions Tailored or more intensive treatment not essential Neither therapy nor meds are essential Monitor weekly to prevent remission of alcohol / drug problem

48. Tips for Treating Smoking in Those with Mental Health Disorder Therapists already have many of the skills needed, only brief training needed for most clinicians Associate with nonsmoking friends Buddy systems with ex-smokers

49. Does Cessation Precipitate Psychiatric Relapse? 0-18% of smokers with past history of MDD relapse during abstinence The mental health of most smokers improves with abstinence

50. Long-term Effect of Smoking Cessation

51. Long-Term Effect of Cessation

52. Tips for Motivating Cessation in Patients with Mental Health Conditions Combat prior messages that patient lacks ability to quit Consider small steps: e.g. reduction Reduction may not reduce health risks but does increase later quitting

53. Tips for Treating Smoking in People with Mental Health Conditions Recommend proven therapies Not necessary to use tailored or more intensive treatment Monitor closely to prevent remission of mental health condition

54. Summary Nicotine produces psychological benefits Smokers with mental disorders often die from smoking-related illnesses Those with mental disorders more likely to start and less likely to quit smoking Increasing quit attempts as important as, if not more important than, aiding quit attempts

55. Summary Social support, especially from peers, important May want to begin with reduction goal Mental health clinicians have many of the skills need to motivate and help smokers quit Acquiring expertise is easy

56. Summary May not need tailored or more intensive treatment Abstinence symptoms can mimic psychological symptoms Abstinence can change levels of psychiatric medications Abstinence may increase relapse of mental disorder in small minority

57. Association for the Treatment of Tobacco Use and Dependence An organization of providers dedicated to the promotion of and increased access to evidence-based tobacco treatment for the tobacco user. www.attud.org