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Promoting smoking cessation in people with schizophrenia

by Meg Fluharty @MegEliz_

This blog originally appeared on the Mental Elf site on 14th May 2015.

shutterstock_276469196People with schizophrenia have a considerable reduction in life expectancy compared to the general population (Osborn et al 2007; Lawrence et al 2013). A number of factors lead to cardiovascular disease (Osborn et al 2007; Lawrence et al 2013; Nielsen et al, 2010) one of which is smoking.People with schizophrenia smoke at much higher rates and more heavily than the general population (Ruther et al 2014, Hartz et al 2014).Stubbs et al (2015) carried out a review to assess the current cessation interventions available for individuals with serious mental illnesses and establish if any disparities currently lie in the delivery of these interventions.60% of premature deaths in people with schizophrenia are due to medical conditions including heart and lung disease and infectious illness caused by modifiable risk factors such as smoking, alcohol consumption and intravenous drug use.

Methods

The authors searched several electronic databases (Embase, PubMed, and CINAHL) using the following keywords: “smoking cessation”, “smoking”, “mental illness”, “serious mental illness” and “schizophrenia.”

Studies were eligible if they included individuals with a DSM or ICD-10 diagnosis of schizophrenia and reported a cessation intervention.

The authors included both observational and intervention studies as well as systematic-reviews and meta-analyses.

This paper is a clinical overview (not a systematic review) of a wide range of different studies relevant to smoking cessation in schizophrenia and other severe mental illnesses.

Results

Pharmacological interventions

 Non-pharmacological interventions

  • The evidence for E-cigarettes was inconsistent, with the authors concluding more evidence was needed before clinicians consider e-cigarettes within mental health settings. Additionally, e-cigarette use in people with schizophrenia should have side effects monitored closely.
  • There was little research on exercise in schizophrenia, but one study found a reduction in tobacco consumption.

Behavioural approaches

  • Behavioural approaches such as offering smoking cessation advice alongside pharmacotherapy have been found successful with no harmful side effects.

Disparities in smoking cessation interventions

  • An investigation of GP practices found individuals with schizophrenia did not receive smoking cessation interventions proportional to their needs.

Support while quitting

  • People with serious mental illnesses experience more severe withdrawal symptoms compared to the general population, and therefore should be given extra support during cessation attempts (Ruther et al 2014).
  • Psychiatrists should re-evaluate choice and the dose of antipsychotic medicine being given after abstinence from smoking is achieved. This is because of nicotine’s metabolic influence on antipsychotic medicine.
  • Alongside smoking cessation, exercise should be promoted among people with schizophrenia to combat weight gain and the increased metabolic risk.

People with serious mental illness are likely to need more support when quitting smoking, because they generally suffer more severe withdrawal symptoms.

Discussion

In light of the findings, the authors suggest several steps for clinicians to help people with schizophrenia quit smoking:

  • Patients’ current smoking status, nicotine dependency, and previous quit attempts should be assessed. Assessing nicotine dependency will help predict the level of withdrawal symptoms the patient is likely to experience upon quitting.
  • Cessation attempts are best timed when the patient is stable. Patients should be thoroughly advised on the process needed to give them the best chance of quitting smoking, Thus, allowing the patient to formulate their quit plan and take ownership of their own quit attempt.
  • Cessation counselling should be provided, particularly what to expect with withdrawal symptoms (e.g. depression and restlessness) and how to cope.
  • Pharmacological support should be provided (Bupropion recommended) when there is even mild tobacco dependence.
  • Clinicians should carefully monitor patients’ medication and fluxions in weight for a minimum of 6 months after quitting smoking, and when needed recommended exercise to combat weight gain.

The authors provide a well laid out summary of their findings, alongside some excellent suggestions for clinicians to consider on how to best promote cessation in practice.

However, it should be stressed that Stubbs et al (2015) only searched for high qualities studies and provided an overview of them –  this is not a systematic review or meta-analysis. They included several types of studies, set little inclusion criteria and listed no exclusion criteria. This is quite different from a systematic review with a meta-analysis, which would set stricter predefined search and eligibility criteria, which identify a set of studies all tackling the same question, thus allowing for the statistical pooling and comparison of these studies.

This is not a systematic review, but it does offer some very useful practical advice for clinicians who are trying to promote smoking cessation.

Links

Primary paper

Stubbs B, Vancampfort D, Bobes J, De Hert M, Mitchell AJ. How can we promote smoking cessation in people with schizophrenia in practice? A clinical overview. Acta Psychiatrica Scandinavica. 2015: 1-9. 
[PubMed abstract]

Other references

Osborn DPJ, Levy G, Nazareth I, Petersen I, Islam A, King MB. Relative risk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom’s General Practice Research Database. Arch Gen Psychiatry 2007;64:242–249.

Lawrence D, Hancock KJ, Kisely S. The gap in life expectancy from preventable physical illness in psychi- atric patients in Western Australia: retrospective analysis of population based registers. BMJ 2013;346: f2539-f.

Nielsen RE, Uggerby AS, Jensen SOW, McGrath JJ. Increasing mortality gap for patients diagnosed with schizophrenia over the last three decades – a Danish nationwide study from 1980 to 2010. Schizophr Res 2013;146:22–27.  
[PubMed abstract]

Ruther T, Bobes J, de Hert M et al. EPA guidance on tobacco dependence and strategies for smoking cessation in people with mental illness. Eur Psychiatry 2014;29:65– 82. 
[PubMed abstract]

Hartz SM, Pato CN, Medeiros H et al. Comorbidity of severe psychotic disorders with measures of substance use. JAMA Psychiatry 2014;71:248–254.

 

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