"Enjoy your cigarettes; it's all you have"

CrossCurrents

By Anne Ptasznik

 

Even though Michael Elson's previous attempts to quit smoking failed, he’s "definitely going to try again." Elson, 34, loves the ritual of his morning cigarette, but says smoking is affecting his health and his wife wants him to quit. The challenge for Elson, who has schizophrenia and works as a peer support worker with an ACT team in Belleville, Ontario, has been finding smoking cessation supports that don’t significantly alter his mood and increase his stress level.

Elson’s addiction and his struggle to overcome it are common among people with mental health problems. A literature review by the Centre for Addictions Research of British Columbia (CARBC) found that prevalence rates of tobacco use among people with mental health issues range from 50 to 90 per cent, compared to about 20 per cent for the general population. In fact, people with mental illness consume more tobacco than any other population in the Western world. According to Dr. Joy Johnson, a nursing professor at the University of British Columbia in Vancouver and lead author of the report, “People with schizophrenia are more likely to die from the effects of their tobacco use than they are from their mental illness.” Yet despite this startling fact, most mental health professionals do not address tobacco use with their clients.

Complex clinical and institutional issues underlie this culture of acceptance of smoking. But some leading smoking cessation researchers and clinicians have taken on the challenge and are working towards changing attitudes, improving institutional responses and developing innovative treatment approaches targeting this deadly killer.

Johnson heads the CACTUS project (Cultivating Awareness of the Context of Tobacco Use), which surveyed 789 smoking and non­smoking clients of community mental health teams and 282 mental health providers in the Vancouver area.  "What surprised me most was the number of clients we surveyed who smoked and who had actually indicated some desire to either cut down or quit smoking,” says Johnson. "Many of us assume that people with mental illness enjoy their cigarettes so much that they wouldn’t contemplate quitting, but that wasn’t the case."

The survey found high concern about the health and economic costs of smoking. Cigarettes leave people with mental illness with little spending money for food and bus fare; some are forced to “bum” cigarettes from friends or strangers or even pick cigarette butts off the ground. Some surveyed clients had lung infections, emphysema and pneumonia, which are commonly associated with heavy tobacco use. Most felt judged by others for smoking.

For people with mental illness, smoking may have a particularly strong hold due to biological mechanisms that may provide a “beneficial” effect of nicotine, according to the CARBC review. Nicotine triggers the “reward system” neurotransmitters dopamine, norepinephrine and serotonin, which elevate mood. Nicotine also helps people to relax and deal with stress and has been found to moderate some of the symptoms of schizophrenia including lack of motivation and energy and affective blunting. Nicotine has also been found to enhance concentration, information processing and learning, which may be impaired due to the illness. Nicotine withdrawal can lead to increased cravings and agitation, staved off only by more nicotine.

Smoking may also alleviate medication side effects, but tobacco can affect the metabolism of medications, resulting in the need for more medication at additional cost. Long-term cigarette smoking may also work to “correct” the biological abnormalities among people who have major depression.

The confusion between nicotine’s purported benefits and the hazards of tobacco use may precipitate acceptance of smoking among this population. Almost all of the mental health professionals in the CACTUS survey believed that smoking helps their clients cope with stress and manage symptoms, that clients had more pressing issues than quitting smoking and that smoking was one of their clients’ few enjoyments in life. They also indicated that staff sometimes use cigarettes to help build a “therapeutic alliance” with clients. In a 2000 study in Psychiatric Services, a client reported that family members, program counsellors and others advised, “Enjoy your cigarettes; it’s the only thing you have …You don’t really have that much in life – you’ve got a mental illness.”

Dr. Charl Els, an addiction psychiatrist at the University of Alberta Hospital and the Alberta director of Physicians for a Smoke­Free Canada, says that while nicotine may have benefits for this population, “the cons of smoking still far outweigh any potential pros.” Els acted as the external consultant when the Alberta Capital Health region authority directed all hospital and community health care facilities to become smoke­free within a three­month time frame. He says that the most resistance came not from clients, but from staff, who said that going smoke­free was inhumane and expressed concerns about increased aggressive behaviour. But Els says the evidence suggests that when given pharmaceutical nicotine replacements, clients are generally comfortable; they don’t leave against medical advice and there’s no increased level of violence.

Els also contends that tobacco policies in health care institutions are not about forcing clients to quit; they reflect an occupational health issue “to get staff to breathe clean air” and assist clients comfortably through a smoke­free hospital admission. Research conducted by Dr. Judith Prochaska, an assistant psychiatry professor at the University of California, San Francisco, published in Psychiatric Services in 2004 showed that smokers on an inpatient psychiatric unit who were not given nicotine replacement therapy (NRT) were twice as likely as non­smokers and smokers given NRT to leave the hospital without medical advice.

Smoking cessation programming, however, must start with more training for mental health professionals. A study of graduate psychiatric nursing education programs published in 2008 in the Journal of the American Psychiatric Nurses Association found that most graduate psychiatric nurses were inadequately trained in tobacco intervention. In the CACTUS study, Johnson says that while all mental health professionals thought smoking was an important issue, “nobody thought it was their job to do it, and nobody felt they had the skills to do it.” In the Alberta region, Els says 200 health care staff received training in tobacco dependence treatments.

But what happens when clients leave the hospital? A study con­ducted at the Cape Cod Hospital in Hannis, Massachusetts, published in 1991in Hospital and Community Psychiatry found that involuntary smoking cessation, client education and nicotine gum were insuffi­cient to help clients stop smoking over the long term after they re­entered the community. Years later, these findings seem to hold: In a 2006 study in the American Journal of Addictions Prochaska found that all clients in a smoke­free psychiatry unit returned to smoking within five weeks of hospital discharge; in fact, many were smoking within five minutes of leaving the unit. In a more recent clinical study, Els found that not only do people with mental illness need NRT or medication to help them quit smoking, but the duration of treatment and access to NRT also need to be open ended.

Dr. Tony George, chair of Addiction Psychiatry at the University of Toronto and clinical director of the Schizophrenia Program at the Centre for Addiction and Mental Health in Toronto, says that behavioural treatment, along with NRT, is essential. In a study published in 2008 in Biological Psychiatry, George and colleagues examined pharmacological and behavioural treatments for smoking cessation among people with schizophrenia and schizoaffective disorder. All participants received pharmacological treatment and weekly group behavioural therapy to teach them the skills needed to quit smoking. Ten per cent of participants who used only the nicotine patch quit smoking, and 35 per cent of those who used the patch and buproprion (Zyban) were able to quit. George says the usual quit rate for this population is between 5 and 10 per cent, compared with 35 per cent in the general population. As the study participants were outpatients, most of whom lived in rooming houses with other smokers, George says this quit rate would not have been possible if participants had not learned the skills to refuse cigarettes.

Prochaska says that longer­term cessation requires motivational interventions and pharmacological and behavioural treatments that are extended over time after clients leave the hospital. In a randomized clinical trial with smokers who were receiving outpatient treatment for depression, participants, who did not have to be interested in quitting, received computerized motivational feedback based on the stages of change and six sessions of psychological counselling along with NRT. Abstinence was higher among this group at 12 and 18 months compared to a control group that only received a self­help guide and referral list of local smoking treatment providers. Prochaska and her colleagues are part­way through a clinical trial, funded by the National Institute on Drug Abuse (NIDA), using a similar approach on the inpatient unit. Although it is premature to disclose the quit rates, Prochaska says they look promising.

Prochaska says that what she found most disturbing when she analyzed formerly secret tobacco industry documents was industry funding of researchers to try and promote the idea that people with mental illness need to smoke – the self­medication hypothesis. She says if this area of study shows some potential, then it’s good to explore it, but she is more concerned that clients aren’t getting effective NRT.

The area of cognitive deficits, which are common among people with schizophrenia, is indeed being studied as a possible basis for developing targeted treatments. In a study published in a 2005 issue of the Archives of General Psychiatry, George and his Yale University associates found that cigarette smoking had some beneficial enhancement on visual spatial working memory and attentional deficits in smokers with schizophrenia. Dr. Jeff Daskalakis, a psychiatrist with CAMH’s Schizophrenia Program and an expert in repetitive transcranial magnetic stimulation (rTMS), has found that stimulating particular regions of the brain with a magnetic pulse reverses the same cognitive deficits that smoking does in people with schizophrenia. George and Daskalakis have obtained Canadian Institutes of Health Research funding to determine whether using rTMS to correct the cognitive deficits, addressing the underlying reason why some people with schizophrenia smoke, along with behavioural treatments and the nicotine patch, will lead to a potential tailored smoking cessation strategy for people with schizophrenia. George has recently completed a similar pilot study using atomoxetine (Strattera), a non­stimulant drug approved for the treatment of attention­deficit/hyperactivity disorder, which seems to have the same effect as rTMS in correcting these cognitive deficits.

People with depression may also benefit from this approach. “The conventional wisdom was that people with depression smoke so much because nicotine has an antidepressant effect,” says George. He was lead author of a study published in the June 2008 issue of the Journal of Clinical Psychopharmacology that found that when people with depression who don’t respond to SSRI antidepressants are given mecamylamine hydrochloride, a nicotine­like drug, their depression disappears and the antidepressants start to work. Similar to the rTMS study, if the underlying reason why some people with depression smoke is treated, this could work as a targeted smoking cessation strategy along with other forms of treatment. George is currently building a concurrent disorders lab at CAMH, which will study the mechanisms underlying why people with mental illness have high rates of addiction, including smoking, and vice versa, in a con­trolled setting.

George says that the most vulnerable people in society have been dying from something that is “very treatable.” Based on the work of these leading smoking cessation experts, this culture of inaction may become a thing of the past.

 

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