Psychological Interventions for Tobacco Dependence

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Psychiatric Morbidity and Smoking Cessation
Stevens S. Smith, Ph.D. Assistant Professor /
Licensed Psychologist Department of
Medicine University of Wisconsin School of
Medicine and Public Health Center for Tobacco
Research and Intervention
GIM Primary Care Conference Presentation October
25, 2006
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Disclosure Statement

• I have received research support (but no
  consulting or speaking fees) from the following
  companies that market smoking cessation
  medications

• SmithKline Beecham
• GlaxoSmithKline
• Elan Corporation, plc

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Learning Objectives

• Psychiatric morbidity and cessation in two case
  studies
• Influence of psychiatric morbidity on smoking
  cessation
• Evidence-based cessation treatment for smokers
  with psychiatric disorders

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Case Studies
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Case Studies
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Case Studies Smoking History
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Progress Dramatic Decrease in Adult Smoking
Prevalence Over 40 Years
1965 2005
Number Percent
Number Percent
Current 50 million 42.4 47
million 20.9 Former 16 million
13.6 51 million 21.5 Never 52
million 44.0 135 million 57.6
(Source National Health Interview Surveys,
1965-2005)
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20.9
42.4
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Remaining Challenges

• gt 400,000 deaths per year nationally (8000 in WI)
• 2,000 children and adolescents become regular
  smokers each day
• 75 billion in added healthcare costs
• 80 billion in lost productivity
• Low rates of clinical assistance with quitting

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2003 Wisconsin Tobacco Survey
Long-term success rate of cold turkey method is
about 5
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Disproportionate Smoking Rates

• The highest rates of smoking are seen in
  individuals
• living below the poverty level
• with the least education
• working in blue-collar and service jobs
• with psychiatric and substance use disorders

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Tobacco Dependence and Mental Illness

• Individuals with mental disorders typically smoke
  more cigarettes per day and they have greater
  difficulty quitting smoking
• Individuals with a current psychiatric disorder
  currently make up about 30 of the population but
  consume 46 percent of all cigarettes smoked in
  the U.S.

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Smoking Status and Mental Illness The National
Comorbidity Survey
(Source Lasser et al., JAMA. 20002842606-2610)
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Smoking Status and Mental Illness The National
Comorbidity Survey

• Current
• Past 30 Days Smoking Quit Rate,
• No Mental Illness 23 43
• Major Depression 45 26
• Nonaffective Psychosis 45 0
• Gen. Anxiety Disorder 55 29
• Alcohol Abuse or Dependence 56 17
• Bipolar Disorder 61 26
• Drug Abuse or Dependence 68 22

(Source Lasser et al., JAMA. 20002842606-2610)
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Smoking Rate and Number of Lifetime Psychiatric
Diagnoses
(Adapted from Lasser et al., 2000)
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Tobacco Dependence and Mental Illness

• Smokers with mental illnesses are aware of the
  health risks of smoking
• However, nicotine may alleviate positive and
  negative psychiatric symptoms as well as side
  effects of psychiatric medications
• Effective smoking cessation treatments are
  available for smokers with mental illness

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U.S. Public Health Service Clinical Practice
Guideline Michael C. Fiore, MD, MPH Panel
Chair Published June, 2000 Evidence-based 50
meta-analyses of 6000 articles (1975-1999)
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Putting the 5 As into PRACTICE ASK ADVISE
ASSESS ASSIST- ARRANGE

• Help develop a quit plan
• Provide practical counseling
• Provide intra-treatment social support
• Encourage the smoker to seek social support
• Recommend pharmacotherapy except in special
  circumstances
• Provide supplementary materials

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ASK ADVISE ASSESS ASSIST-
ARRANGE Pharmacotherapy

• The Guideline recommends the use of FDA-approved
  pharmacotherapy, except when contraindicated
• First-line medications Bupropion SR,
  nicotine patch, nicotine gum, nicotine
  inhaler, nicotine nasal spray
• Second-line medications Clonidine,
  nortriptyline
• (Although not available when the 2000 Guideline
  was developed, consider OTC nicotine lozenge,
  varenicline)

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Who Should Receive Pharmacotherapy?

• The Guideline recommends that ALL smokers trying
  to quit should be offered cessation medication
  except for special circumstances
• - medical contraindications
• - smoke lt 10 cigarettes/day
• - pregnant/breastfeeding
• - adolescent smokers

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Guideline Recommendations for Smokers With
Psychiatric Comorbidities

• The antidepressants bupropion SR and
  nortriptyline should be considered for smokers
  with current or past history of depression
• Stopping smoking may affect the pharmacokinetics
  of certain psychiatric medications need to
  monitor
• No specific recommendations in the Guideline for
  treating smokers with anxiety disorders

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General Recommendations for Depressed Smokers

• Smoking cessation treatment can be initiated in
  depressed smokers who are motivated to quit and
  clinically stable
• Consider prescribing bupropion SR or
  nortriptyline (as appropriate given other
  possible psychotropic meds)
• Consider nicotine replacement therapy (NRT)
  either as a first-line pharmacotherapy or to
  augment bupropion SR or nortriptyline

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General Recommendations for Depressed Smokers

• Consider varenicline as another first-line
  pharmacotherapy but do not combine with NRTs
• There are no clinical studies of varenicline in
  combination with bupropion SR or nortriptyline
  (no concern about drug interactions according to
  Michael Fiore, M.D.)
• Consider referral to a mental health specialist
  especially if the smokers depression is not
  responding to antidepressant pharmacotherapy alone

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General Recommendations for Smokers With an
Anxiety Disorder

• Smoking cessation treatment can be initiated in
  anxious smokers who are motivated to quit and
  clinically stable
• Neither bupropion SR nor nortriptyline are
  recommended for patients with anxiety disorders
• SSRIs and benzodiazepines are commonly prescribed
  for anxious patients neither of these has shown
  efficacy for smoking cessation

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General Recommendations for Smokers With an
Anxiety Disorder

• Consider nicotine replacement medication as the
  first-line pharmacotherapy
• Consider varenicline as another first-line
  pharmacotherapy but do not combine with NRTs
• Consider referral to a mental health specialist
  especially if the smokers anxiety is not
  responding to pharmacotherapy alone

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Real-World Use of Combination Pharmacotherapy
Source University of Medicine Dentistry of New
Jersey Tobacco Dependence Clinic Annual
Report 2004
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Case Studies
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Contact Information
Stevens S. Smith, Ph.D. Phone [phone] sss_at_c
tri.medicine.wisc.edu www.ctri.medicine.wisc.edu