Patients with severe mental disorders (SMI) such as schizophrenia have a significantly shorter life expectancy compared to the general population, and somatic co-morbidities, especially cardiovascular disease, play an important role in this. As one of the modifiable lifestyle factors, smoking cessation initiatives for patients with schizophrenia are promising, but face many challenges.
I. The dangers of smoking
Smoking is the most common substance use disorder in people with mental disorders, with rates two to four times higher than in the general population. Patients with SMI, including schizophrenia, have particularly high rates of smoking and are often heavy smokers; at the same time, smoking is particularly damaging to patients with schizophrenia. Studies have shown that 53% of deaths in patients with schizophrenia are attributable to tobacco-related health events, including cancer (standardized mortality rate [SMR] 1.30), cardiovascular disease (SMR 2.46), and respiratory disease (SMR 2.45). Patients with schizophrenia who smoke have worse health outcomes compared to nonsmoking patients. There is also recent evidence that tobacco has a negative effect on working memory and hippocampal volume in schizophrenia patients.
Second, what makes it difficult for people with schizophrenia to quit smoking?
In stark contrast to the general population, smoking cessation campaigns are struggling to advance among people with schizophrenia, and the gap between the two smoking rates is widening. The reasons for this.
The schizophrenia population may face more significant barriers to smoking cessation, including neurobiological and psychosocial factors.
Patients have lower levels of awareness of the health risks of smoking and are relatively less motivated to quit.
previous studies suggesting that psychiatric conditions may worsen in patients with mental disorders if they quit smoking (however, this concern is redundant when patients are mentally stable)
Some public health strategies that are effective for the general population, such as media campaigns and higher tobacco prices, appear to be ineffective for people with mental disorders, and higher tobacco prices have in turn somewhat exacerbated the socioeconomic disadvantage of this group.
III. Smoke-free wards and the attitudes of health care workers
Smoke-free wards discourage smoking, which in turn has the effect of helping patients to abstain from smoking. It is clear that health care staff play an important role in patients’ quitting smoking, yet studies have shown that 60% of staff believe they should smoke with patients, 54% believe smoking has a therapeutic effect on patients, and 93% believe patients’ inability to smoke may lead to worsening of their condition. A higher percentage of nurses who smoked themselves believed that patients should be allowed to smoke and that smoking had a positive therapeutic effect than did doctors. In this context, there is resistance to designating smoke-free areas in the wards. Therefore, smoking cessation education should also be incorporated into health care staff at the same time.
IV. What cessation tools are effective?
Pharmacological interventions
Nicotine replacement therapy (NRT)
is effective in the general population, with little evidence in patients with schizophrenia, but this does not mean that NRT is ineffective in patients with schizophrenia, only that there is a lack of high-quality evidence with sufficiently long follow-up periods. The European Psychiatric Association (EPA) guidelines are bullish on the future of NRT in patients with schizophrenia.
Bupropion
An analysis pooling five studies showed that bupropion helped patients with SMI to quit smoking compared to placebo (RR 2.77, 95% CI 1.48C5.16), mainly in patients with schizophrenia. Another Cochrane review reported similar effect values (RR 3.03, 95% CI 1.69C5.42, N = 7, n = 340), also after 6 months (RR 2.78, 95% CI 1.02C7.58, N = 5). During this time, patients did not experience serious adverse effects or worsening of their mental status, except for milder negative regressions such as headache and insomnia.
Overall, bupropion is an effective adjunct to smoking cessation for patients with schizophrenia. Although there are concerns about the effects of this drug on suicide risk, there is no evidence to support this and no data to suggest that this treatment worsens psychiatric symptoms.
Varenicline
EPA guidelines and several systematic reviews are optimistic about the effectiveness of varenicline as an aid to smoking cessation, but the evidence remains limited. The results of previous studies are controversial, but some of them have had enrollment problems. Overall, varenicline has the potential to aid smoking cessation in patients with schizophrenia, but longer RCTs are needed, and patients’ psychiatric symptoms need to be taken into account, especially in monitoring those at risk for self-injury and suicide.
Non-pharmacological interventions
Electronic cigarettes
Electronic cigarettes are quite popular in the general population and are considered a less risky alternative treatment option than pharmacological interventions. Few studies have been conducted on patients with schizophrenia. A small prospective study that included 14 subjects showed that e-cigarettes reduced the number of cigarettes smoked per day by 50% in half of them, but patients experienced multiple side effects, including nausea (2/14), throat irritation symptoms (2/14), headache (2/14), and dry cough (4/14). A recent study that included 255 psychiatric patients showed that e-cigarettes were not associated with changes in smoking status and number of cigarettes smoked per day.
In conclusion, e-cigarettes can be a potential option, but also need to be monitored for adverse effects during treatment.
Exercise
Physical exercise helps the general population quit smoking and may also help reduce cravings and withdrawal symptoms. However, fewer studies have been conducted in patients with schizophrenia. In the only pilot study to date, after an 8-week counseling and exercise intervention, patients experienced a 50% decrease in tobacco consumption and a significant decrease in carbon monoxide exhalation.
Behavioral and psychosocial interventions
Many behavioral interventions are available, but the most common and simple is to provide advice on smoking cessation. Multiple meta-analyses have shown that simply providing advice to quit smoking is effective in increasing the chances that the general population will try and succeed in quitting. Behavioral and psychosocial interventions are often used in combination with pharmacotherapy. Evidence suggests that psychosocial interventions are effective in the short term, with post-treatment success rates of up to 42%. In addition, such tools are well tolerated and have no direct effect on psychiatric symptoms.
V. After stopping smoking
Withdrawal symptoms
Symptoms in the post-stop phase are more common in the general population and may result in physical symptoms, including palpitations and hypotension; and psychological symptoms, such as difficulty concentrating and sleep problems. These symptoms typically peak 24-48 hours after stopping smoking and disappear after 10 days. In general, withdrawal symptoms may be more severe in patients with SMI and should be supported accordingly.
Review of therapeutic medications
Smoking can significantly affect the metabolism of many psychotropic medications. Experts recommend that once a patient with schizophrenia has successfully quit smoking, the psychiatrist should review
the type of antipsychotic and its dose, and that the effect of nicotine on the metabolism of different antipsychotics varies. A more visual example: studies have shown that 41.7% of patients using clozapine after a local smoking ban was enacted had clozapine blood levels >1000 μg/L, compared to 4.2% before the enactment. EPA guidelines also recommend that clozapine blood levels be monitored carefully after cessation of smoking in patients using clozapine.
Weight gain and risk of diabetes
A newly published meta-analysis of the general population showed that individuals could gain 4.67 kg (95% CI 3.96C5.38) in weight within 12 months of quitting smoking; another meta-analysis showed that in the general population, stopping smoking was associated with an increased risk of diabetes (RR 1.44, 95% CI 1.31C1.58). Given that patients with schizophrenia are already at risk for weight gain and type 2 diabetes, the above issues should be taken into account. One approach is to increase physical activity, as well as to start with diet.
Special recommendations for people with high nicotine dependence
There are many heavy smokers among patients with schizophrenia, some of whom are highly dependent on nicotine, may have tried smoking multiple times previously, and need additional help. This group may benefit from higher doses of NRT, and e-cigarettes may also line up. Although the effectiveness of the above treatments has not been clarified, it is clear that these options are always preferable to continued smoking.
VI. Five Steps to Quit Smoking
(i) Assessing nicotine dependence
The Fagerstrom Test of Nicotine Dependence (FTND) is the most widely accepted assessment tool internationally. The scale is based on six questions that measure the severity of different dimensions of somatic dependence in smokers, with a total score of 10, 0-2 being no dependence or very mild dependence, 3 or 4 being mild dependence, 5 being moderate dependence, and ≥6 being high dependence. If conditions do not permit, at least two of these entries should be used, i.e., time of first cigarette in the morning and number of cigarettes smoked per day, as these two factors are most strongly correlated with nicotine dependence. The patient’s previous quit attempts should also be asked. A nicotine-dependence-specific assessment can help predict the likelihood that a patient will experience withdrawal symptoms.
In addition, carbon monoxide exhalation can also be used to assess smoking status and correlates with FTND results.
(ii) Agreeing on a cessation process
Communication with all smokers should be clear and non-ambiguous, supportive and non-confrontational. The best time to quit is when the patient is stable and has not recently adjusted psychotropic medications. It is important that the consequences of tobacco dependence be clearly communicated to the smoker and that detailed information about the cessation process be provided to the smoker to facilitate active participation and self-management.
(iii) Provide cessation counseling
Evidence suggests that the provision of the “5A” framework may have long-term benefits for smoking-related regression. The “5As” include
Asking: Asking (asking patients about their smoking status)
Advising (providing clear, strong advice on the health effects of smoking, combined with individualized information)
Assessing: Evaluating (assessing the smoker’s willingness to stop smoking)
Assisting (recommending approved medications and referrals to smoking cessation clinic structures)
Arranging: arranging (assessing smoking status at each follow-up visit, reinforcing/encouraging cessation)
The EPA recommends that smokers be especially prepared for withdrawal symptoms, such as short-term restlessness and anxiety, and that exercise help alleviate these potential problems. In addition, alternative means of coping with stressful situations and possible anxiety should be further explored with the smoker, as this may improve the patient’s transition.
If the patient is reluctant to quit, a “5Rs” motivational intervention can be used to increase motivation to quit. The “5 R’s” include.
Relevance: Relevance (making it clear to smokers why quitting is relevant to them)
Risks: Risks (making clear to smokers the negative consequences of smoking)
Reward: The potential benefits of treatment and the rewards of quitting are made clear to smokers.
Roadblocks: roadblocks (so that smokers can identify the roadblocks that prevent them from quitting)
Repetition: Repeat (each time a patient with low motivation comes to the clinic, the above steps are repeated)
(iv) Provide pharmacotherapy support
First-line pharmacotherapy (bupropion, NRT, and varenicline) should be used even if the level of tobacco dependence is only mild. See above for details.
(v) Monitor therapeutic medications, weight, metabolic markers, and provide exercise
Given that smoking may lead to significant changes in levels of psychoactive drugs (especially clozapine), the multidisciplinary treatment team should monitor clozapine blood levels for at least 6 months after the patient has quit smoking. Although the evidence is sparse, evidence from the general population suggests that cessation of smoking is associated with weight gain and increased risk of diabetes. Clinicians should likewise monitor the patient’s exercise to alleviate these concerns and perhaps also to reduce the patient’s craving behavior.
Conclusion
The evidence for pharmacologic adjuncts to smoking cessation is limited but growing, with bupropion having particular potential. A number of behavioral and psychosocial interventions have shown some potential, especially when combined with pharmacotherapy. The most effective cessation strategy is likely to be medication + psychosocial + exercise. Specifically, clinicians are recommended to use a five-step strategy.