Tobacco Use in Special Populations: Psychiatric and Substance Use Disorders

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Tobacco Use in Special Populations Psychiatric
and Substance Use Disorders

• Eric Heiligenstein, M.D.
• Clinical Director, Psychiatry Service
• University Health Services
• Associate, CTRI
• University of Wisconsin-Madison

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Tobacco Use Disparities

• Ethnic minorities
• Low SES
• Pregnant women
• Youth
• Coexisting psychiatric and substance use disorders

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Objectives

• Identify disproportionate smoking rates among
  individuals experiencing psychiatric disorders
• Understand the additive morbidity and mortality
  to individuals with psychiatric disorders
• Discuss integration of tobacco use identification
  and cessation efforts into mental
  health/substance abuse practices
• Understand the concurrent treatment needs of
  individuals with psychiatric disorders when they
  are treated for nicotine dependence

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Association of Smoking and Psychiatric Disorders

• Rates among specific diagnoses
• General population
• 20.9
• Panic disorder
• 35
• Depression
• 49
• Alcohol dependence
• 80
• Schizophrenia/Bipolar Disorder
• 88
• Hughes, 1986

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Consume 45 of cigarettes smoked in U.SBreslau,
2003
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Smoking Rates Compared to the Number of Lifetime
Psychiatric Diagnoses
Adapted from Lasser, 2000
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Smoking and Mental Health Problems in
Treatment-Seeking University Students (n503)

• Heavy smokers compared to light and non-smokers
• Poorer overall well-being
• Greater functional impairment
• More severe depression and anxiety
• Smoking is severity of illness multiplier

Heiligenstein and Smith, NTR, 2006
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Additional Complications of Smoking and
Psychiatric Disorders

• Additive mortality risks
• Heart disease is 7X higher than peers and more
  than 7x the suicide rate.
  Department of Mental Health,
  Massachusetts, 2001
• Affects psychotropic blood levels
• Depressed smokers have higher suicide rates than
  depressed nonsmokers
• Bruce, 1994
• Lohr, 1992
• Yassa, 1987

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Fundamental Problems Smokers with Psychiatric
Disorders

• Neurobiological factors reinforce use of nicotine
• Feel excluded from mainstream cessation programs
• Lower rate of quit attempts
• Higher tobacco relapse rates

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Fundamental Problems Smokers with Psychiatric
Disorders

• Long considered part of psychiatric culture
• Clinicians believe they are not able/willing to
  quit
• For those with chronic psychiatric disorders
• Major part of daily routine/structure
• Alleviates stigma
• Positive/negative freedoms

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Tobacco Use and Specific Psychiatric Disorders

• Major Depression (MDD)
• Anxiety Disorders
• Alcohol abuse/dependence
• Schizophrenia/Bipolar Disorder

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Smoking and Specific Psychiatric Disorders

• Major Depression (MDD)
• Anxiety Disorders
• Alcohol abuse/dependence
• Schizophrenia/Bipolar Disorder

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Link Between MDD and Smoking
Adapted from Kendler KS, 1993
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Smoking and MDD

• Smokers with a past history of MDD
• More likely to have post-cessation MDD
• Risk greatest first 6 months post-cessation
• Leads to more severe nicotine withdrawal symptoms
• High risk for relapse in first week
• Female riskgtmale
• Quattorocki, 2000
• Niaura, 1999
• Hughes 2007

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NRT and MDD

• NRT alone insufficient treatment for smokers with
  current/past MDD
• No effect on mood
• Cessations rates not improved
• Thorsteinsson, 2001
• Smith, 2003

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SRIs and Smokers with MDD

• No benefit for smoking cessation
• Can offset negative moods during a quit attempt
• Can reduce likelihood of emergent depression
  during quit attempt
• Can be combined with Bupropion/NRT
• Can be combined with varenicline
• Cook, 2004
• Chengappa, 2001
• Smith, 2003

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Bupropion and Smokers with MDD

• Can be used as monotherapy for both problems
• Can be combined with varenicline
• Treatment may need to be extended beyond
  traditional 3-6 months

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Combined Treatments for Depressed Smokers

• Adding CBT to standard treatments show mixed
  results
• No research available for other types of
  non-pharmacological interventions
• Brown, 2007
• Hall, 2006

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Smoking and Specific Psychiatric Disorders

• Major Depression (MDD)
• Anxiety Disorders
• Alcohol abuse/dependence
• Schizophrenia/Bipolar Disorder

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Smoking and Anxiety Disorders

• Smokers have greater anxiety and panic symptoms
  than non-smokers
• Heavy smoking in adolescence associated with
  higher risk of developing
• Agoraphobia
• GAD
• Panic disorder
• Increased risk for relapse during early stages of
  quit attempt
• Breslau, 2004
• Amering, 1999

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SRIs and Smokers with Anxiety Disorders

• No benefit for smoking cessation
• Can reduce likelihood of emergent anxiety or
  panic during quit attempt
• BUP not appropriate as only medication
• Carefully combined with Bupropion/NRT
• Can be combined with varenicline

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Smoking Cessation and PTSD

• Cessation not associated with worsening of PTSD
  symptoms
• Integration into standard care improves quit
  rates
• BUP tolerated and effective treatment
• McFall, 2006
• Hertzberg, 2001

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Smoking and Specific Psychiatric Disorders

• Major Depression (MDD)
• Anxiety Disorders
• Alcohol abuse/dependence
• Schizophrenia/Bipolar Disorder

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Smoking and Alcohol Use

• Individuals are three times as likely to smoke if
  they binge drink
• Consumption of alcohol
• Increases length of time smoking
• Increases number of puffs
• Increases subjective smoking satisfaction
• Dawson, 2000

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Prevalence of Binge Drinking By Smoking Status
Binge Drinking 5 or more drinks in one sitting
3 binges/month
WI Tobacco Survey, 2003
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Smoking and Alcohol Dependence

• Over 72 of alcoholics are heavy smokers (9 of
  general pop.)
• Increased urge to drink among alcoholic smokers
  when they smell cigarettes
• Dawson, 2000

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Alcohol Dependence and Smoking

• Appears to compound alcohol-induced neuronal
  injury
• Continued smoking diminishes recuperation from
  alcohol-related cognitive deficits during alcohol
  abstinence

Durazzo, 2007
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Perfusion images of nonsmoking light drinker
(nsLD) and smoking alcoholic (sALC)




Note lower intensity in GM region of sALC
suggesting lower GM perfusion than in nsLD.
Gazdzinski, 2007
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RTNSlide 16
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Cessation Treatment for Alcohol Users

• Standard cessation treatments are effective
• No evidence of increased use of other substances
  during cessation treatment
• Alcohol abstinence days greatest for those who
  quit smoking
• Saxon, 2003
• Kohn, 2003

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Barriers to Tobacco Dependence Treatment in
Substance Treatment Facilities

• 38 thought best time to treat was when patient
  wanted treatment
• 14 believed their patients benefited from
  smoking
• 25 had advised patients to delay quitting smoking

Richter, 2006
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Smoking and Specific Psychiatric Disorders

• Major Depression (MDD)
• Anxiety Disorders
• Alcohol abuse/dependence
• Schizophrenia/Bipolar Disorder

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Smoking and Schizophrenia/Bipolar Disorder

• Highest smoking rates than any other patient
  group
• Smoke 10 billion pack per year
• More per day
• Prefer high tar, high nicotine
• Smoke to ends of cigarettes
• DMello, 2001

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Smoking Cessation for Schizophrenia/Bipolar
Disorder

• Have lower cessation rates than general
  population
• Cognitive deficits may contribute to cessation
  treatment failure
• Traditional cessation treatments may be
  inadequate
• Harm reduction and NRT
• Hospitalization may be unique opportunities to
  initiate treatment

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BUP for Smoking Cessation in Schizophrenia

• Can lead to smoking reduction
• Quit rates comparable to general population and
  durable
• Quit rates enhanced with CBT
• Overall symptoms not worsened
• Evins, 2004, 2005
• Fatemi, 2005
• George, 2002

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Smoking cessation responses to bupropion and
placebo as a function of antipsychotic class
treatment Adapted from George, 2002
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Mental Health Benefits From Treating Tobacco
Dependence

• Emerging evidence that morbidity is reduced
• May enhance abstinence from substances
• Reduced financial burden
• Increased self-confidence

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Necessary Mental Health Care System Interventions

• Systematic identification processes that mesh
  with a non-medical practice style
• Educational efforts for providers that emphasize
  the detrimental effects of smoking on mental
  health
• Integration of cessation efforts with primary
  mental health treatments
• Address emotional/behavioral comorbidity that
  effect cessation efforts in primary care settings

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Contact Information

• Eric Heiligenstein, M.D.
• elheilig_at_wisc.edu
• 608-262-9199

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Brief Screening for Depression in Smokers

• Have you been consistently depressed, most of the
  day, nearly every day, for the past 2 weeks?
• In the past 2 weeks have you been less interested
  in most things or less able to enjoy things?

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Brief Screening for Anxiety in Smokers

• Do you worry continually almost every day about
  both big and small problems, situations, events,
  and/or activities?
• Does your worrying interfere with your normal
  routines, work or school, and/or social
  activities?

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Brief Screening for Problematic Alcohol Use in
Smokers

• Do you sometimes drink alcoholic beverages?
• How many times in the past years have you had 5/4
  or more drinks in a day?
• On average, how many drinks per week do you have?