Successful Tobacco Dependence Treatment in Schizophrenia

Abstract

Individuals with schizophrenia smoke at rates three times higher than the general population in the United States, with smoking prevalence rates of at least 60% (1, 2). International studies have also typically found increased rates of smoking among persons with schizophrenia (3). A pattern of heavy smoking (more than 20 cigarettes per day) and severe nicotine dependence (4, 5) is characteristic. Smokers with schizophrenia have increased nicotine and cotinine levels that are attributed to increased nicotine intake per cigarette (6–8). Higher blood nicotine levels are associated with greater severity of tobacco dependence and more difficulty quitting. High nicotine levels may be needed for activation of low-affinity alpha-7 nicotinic receptors, which are reduced in both number and function in schizophrenia (9, 10). Evidence for this self-medication hypothesis comes from abnormal electrophysiological measures and saccadic eye movements that are reversed or improved when nicotine is administered by smoking cigarettes or with high-dose nicotine gum or nasal spray (11–13). Despite nicotine being beneficial, tobacco is not a pharmaceutical and is associated with more than 4,000 toxins and more than 60 carcinogens. Nicotine can be delivered more safely in commercially available nicotine products, including gum, nasal spray, inhalers, and patches. Schizophrenia is associated with a 20% reduced life expectancy and increased rates of smoking-related respiratory and cardiovascular diseases compared to members of the general population (14, 15). A 10-year study of elevated risk of coronary heart disease in schizophrenia showed that the risk remained extremely high even after control was added for factors such as weight and body mass index and was attributable mainly to smoking (16). Besides health, tobacco use results in other consequences, with smokers suffering financially and socially. Smokers with schizophrenia spend almost one-third of their monthly disability income on cigarettes (17). Smoking influences community integration because smokers have less income to spend on clothing and housing. As the smoking rate decreases among the general population, there is also the stigma in being a smoker in addition to the stigma of having mental illness. This can reduce success in obtaining employment, housing, or interpersonal relationships. Studies have found that heavy smoking among individuals with schizophrenia is associated with higher levels of positive symptoms and higher antipsychotic medication doses (18, 19). Despite the magnitude of tobacco use problems, quit rates for seriously mentally ill smokers are significantly lower than in the general population (5, 20). Individuals with schizophrenia are able to quit smoking, although the success is about half that of other groups (21–23). Contributing factors likely include lower motivation to quit tobacco use, fewer lifetime quit attempts, and increased severity of nicotine dependence. Another important consideration is that access to treatment for this group is reduced. Few mental health professionals identify and treat tobacco use in their patients (24, 25). Tobacco dependence interventions provided in primary care and public health settings are often brief and may lack the intensity or specialization needed for this population to stop smoking. These services often rely on a highly motivated and organized client who is ready to quit. In 2001, the University of Medicine and Dentistry of New Jersey—Robert Wood Johnson Medical School and Tobacco Dependence Program both collaborated to develop specialized services for smokers with schizophrenia and other mental illnesses. These differed from traditional services in several ways: services were open ended and not limited to a set number of contacts, all patients were encouraged to use a combination approach of pharmacotherapy and counseling, and there was no requirement to set a quit date to be in treatment. An addictions psychiatrist and mental health social worker that was also a certified tobacco treatment specialist provided most services. Both individual and group counseling services were available. More than 300 smokers with schizophrenia and other serious mental illnesses have received these specialty services and achieve long-term abstinence rates as high as those without a history of mental health problems (26). We describe here the treatment of one such patient.