Office Champions Tobacco Cessation Behavioral Health Facts
Each year, more people in the United States die from smoking-related causes than from AIDS, alcohol, cocaine, heroin, homicide, suicide, motor vehicle crashes, and fires combined.1 Tobacco use is the leading preventable cause of disease, disability, and death in the United States.
Statistics indicate that adults who have a behavioral health disorder (i.e., a mental health disorder and/or a substance use disorder) are disproportionately affected by tobacco use. These individuals have higher rates of smoking, find it harder to quit smoking, and face disparities in treatment.
- Adults who have a behavioral health disorder smoke 40% of all cigarettes smoked by adults in the United States.2
- The smoking rate of people who have a mental health disorder (36%) is nearly twice the rate of the general U.S. population (21%).3
- Lifetime smoking rates are even higher in patients who are diagnosed with major depression disorder (59%), bipolar disorder (83%), or schizophrenia and other psychotic disorders (90%).4
- People who have substance use disorders tend to be heavy, highly nicotine-dependent smokers. Individuals who use cocaine (approximately 80%) and opioids (more than 80%) have high rates of comorbid cigarette smoking.5
- More than 80% of youth with substance use disorders report current tobacco use, most report daily smoking, and many become highly dependent, long-term tobacco users.6
- An estimated 200,000 adults who have a mental health disorder and comorbid substance use disorder die from tobacco-related disease each year. This is higher than the general population estimate due to higher smoking prevalence among people who have a behavioral health disorder, as well as disparities in access to prevention and treatment.7
- People who have a mental health disorder are more likely to have stressful living conditions, have a low income, and lack access to health insurance and health care. All of these factors make it more challenging to quit.3
- National data indicate that the quit ratio (i.e., the proportion of people who have ever smoked and then quit) is 34.7% among adults who have a mental health disorder, compared with a 53% quit ratio among those who do not.3
- People who have a mental health disorder and/or substance use disorder want to quit smoking, and want information on cessation services and resources. According to one study, people addicted to cocaine (52%), people who have alcoholism (50%), and people addicted to heroin (42%) were interested in quitting smoking at the time they started treatment for other addictions.8
Medication and Tobacco Use
The following medications are known or suspected to be affected by smoking and smoking cessation:18
Chlorpromazine (Thorazine), Olanzapine (Zyprexa), Clozapine (Clozaril), Thiothixene (Navane), Fluphenazine (Permitil), Trifluoperazine (Stelazine), Haloperidol (Haldol), Ziprasidone (Geodon), and Mesoridazine (Serentil)
Amitriptyline (Elavil), Fluvoxamine (Luvox), Clomimpramine (Anafranil), Imipramine (Tofranil), Desipramine (Norpramin), Mirtazapine (Remeron), Doxepin (Sinequan), Nortriptyline (Pamelor), Duloxetine (Cymbalta), and Trazodone (Desyrel)
Alprazolam (Xanax), Lorazepam (Ativan), Diazepam (Valium), and Oxazepam (Serax)
Acetaminophen Riluzole (Rilutek), Caffeine Ropinirole (Requip), Heparin, Tacrine, Insulin, Warfarin, Rasagiline (Azilect), Riluzole (Rilutek), Ropinirole (Requip), and Tacrine.
According to the American Psychiatric Association, nicotine dependence is the most prevalent substance use disorder among people who have a mental illness.9 The reinforcing, mood-altering effects of nicotine10, genetic factors11, and reduced coping for cessation12 have been identified as contributing
factors to elevated rates of cigarette smoking in people who have co-occurring mental health disorders and/or substance use disorders.
Cigarette smoking appears to be an attempt to self-medicate or cope with symptoms of depression, anxiety, boredom, loneliness, and other feelings common in people who have a mental health disorders.13 Smokers often report that cigarettes improve their mood, anxiety, and concentration.13 However, research studies of cognitive functioning show that nonsmokers outperform smokers in nearly all tasks, and the benefits of smoking seem to be restricted to modest increases in attention during simple, repetitive tasks.14,15
What smokers with mental health disorders often fail to recognize is that they may be using tobacco to simply prevent or treat the unpleasant symptoms of withdrawal the tobacco dependence has created. Withdrawal symptoms include increased anxiety, sadness, agitation, and worsening concentration. These are temporarily alleviated by smoking, but reinforce the cycle of repeated use and are best addressed through pharmacological treatments for tobacco dependence.13
It should also be noted that for people who have a mental health disorder, smoking cigarettes can reduce the therapeutic blood levels of a number of psychiatric medications16 thereby decreasing their effectiveness. Decreased effectiveness of medications can be due to the nicotine and/or tobacco smoke itself. Because it activates the sympathetic nervous system, nicotine can counter the pharmacologic actions of certain drugs.17 The effect on medications needs to be considered when patients quit tobacco use.
Lastly, a challenge exists in the culture and treatment settings in which people who have mental health disorders are treated. Prioritization of mental health treatment19, lack of an appreciation of the negative health effects of cigarette smoking20, and beliefs among clinicians that people who have mental health disorders are not able or willing to quit21 have contributed to a culture in mental health treatment settings that accept and normalize cigarette smoking. Psychiatry settings have a long history of providing cigarettes to patients as a reward for other treatment compliance.21 In fact, as recent as the 1990s the tobacco industry and some mental health patient advocacy groups fought efforts by hospitals, states, and the Joint Commission on Accreditation of Healthcare Organizations to ban cigarette smoking in inpatient psychiatric facilities.22
Approximately 70% of people who use tobacco products see a physician each year, so family physicians have the opportunity to make a significant impact on their patients’ tobacco use,23 including those who have behavioral health disorders. Research indicates that 69% of people who currently smoke among the general population would like to quit smoking, and 52% try to quit smoking at some point in the course of a year.24
As noted, there exists a stigma that people who have mental health disorders are not able or willing to quit smoking. One survey queried a sample of smokers in treatment for depression about their cessation goals. The results indicated that 33% wanted to quit smoking forever, 47% named some form of reduced smoking as a goal, and only 20% said quitting was not a current goal.25 Similar assumptions of people who have a substance abuse disorder have been made that they do not want to quit smoking. These have also not been supported by research results. Several surveys of people who are in addictions treatment have shown that 44% to 80% are interested in quitting cigarettes.26,27,28,29,30
Despite these rates of people who have a behavioral health disorder expressing a willingness to quit, only 48% of patients who had visited a health care professional in the course of a year reported being advised to quit smoking.28 It is estimated that if physicians advised 90% of people who smoke to quit, and offered them medication or other assistance, 42,000 additional lives could be saved each year.31 Treating tobacco dependence can be considered one of the most important activities a physician can perform for their patients.6
Of the 42.1 million people in the United States who smoke cigarettes, only 5% are able to quit without assistance and support from health care professionals.32,33 Unfortunately, 68% of smokers who try to quit do so on their own without using evidence-based tobacco cessation medications or receiving counseling, and more than 95% relapse.24 The use of evidence-based programs can more than double success rates.34
The U.S. Public Health Service (USPHS) clinical practice guideline Treating Tobacco Use and Dependence: 2008 Update calls on physicians to change the clinical culture and practice patterns in their offices to ensure that every patient who uses tobacco is identified, advised to quit, and offered evidence-based treatments.32 This guideline also calls for systems-level interventions to ensure that tobacco and nicotine
use is assessed at every clinical encounter and treated according to current recommendations. Comprehensive interventions by physicians are well below what is desirable and effective.32
To ensure comprehensive intervention, medical practices need to establish a team-based system to implement the following:
- Record tobacco-use status as a vital sign.
- Use electronic health records (EHRs) that include automatic prompts that remind clinicians to screen for tobacco use and nicotine dependence.
- Define a clear process for assessing interest in quitting, encouraging quitting for those not currently interested, encouraging use of tobacco cessation medications, and following up as appropriate.
- Create a system for non-physician members of the health care team (e.g., nurse, health educator) to provide patients with information and support for quitting.
- Refer patients to the 1-800-QUIT-NOW (1-800-784-8669) quitline, the text messaging service Smokefreetxt (http://smokefree.gov/smokefreetxt(smokefree.gov)), or other counseling resources.
- Initiate automatic follow-up phone calls by a nurse or health educator to patients who have set a quit date.
- Create a flow sheet in the patient’s record to summarize past smoking discussions and quit attempts.34
Quit Date Flexibility
The Treating Tobacco Use and Dependence: 2008 Update guideline recommends that physicians offer treatment for tobacco dependence to patients who have a mental health disorder when psychiatric symptoms are not severe. For this reason, quit dates should be flexible.32
Behavioral health care incorporates mental health care, substance abuse care, health behavior change, and attention to family and other psychosocial factors.35 The integration of behavioral health care into primary care is instrumental in effective tobacco dependence treatment. The American Academy of Family Physicians (AAFP) encourages family physicians to use interventions drawn from behavioral health care to address tobacco and nicotine dependence. Recommended interventions include motivational interviewing, brief interventions, and group visits.
The following AAFP resources provide information about the use of motivational interviewing and other behavioral health care interventions in tobacco dependence treatment:
- Treating Tobacco Dependence
- Treating Tobacco Dependence Practice Manual: Through a Systems-Change Approach(24 page PDF)
- A Guide to Tobacco Cessation Group Visits(14 page PDF)
In addition to AAFP resources, the Smoking Cessation Leadership Center(smokingcessationleadership.ucsf.edu) offers a number of tobacco and tobacco cessation-related resources in the area of behavioral health.
The evidence-based interventions described in these resources can be used with any patient who smokes, not just patients who have a behavioral health disorder. However, counseling and pharmacotherapy must be tailored to the needs of the individual patient. Patients who have a behavioral health disorder will often require more time to prepare to quit, more medical management, more intensive follow-up, and closer medication monitoring than other patients.
Tobacco dependence is a chronic condition characterized by remission and relapse, and family physicians should approach treatment with this in mind.33 Confidence may be an issue for patients who have a behavioral health disorder. They may require more motivation and encouragement to try to quit smoking than other patients. Considering they have other conditions and disorders being treated, it may take these patients longer to quit smoking. Any reduction in tobacco use should be recognized as progress. Careful follow up is also important. Tobacco cessation goals for these patients should be re-evaluated on a regular basis and adjusted as necessary.
Counseling is critical to the success of tobacco dependence treatment. Both individual and group counseling can be effective to support tobacco cessation in patients who have a behavioral health disorder. Counseling should include problem-solving skills training with specific discussions about what to do in certain situations. It should also include reassurance that the health care team will provide ongoing support and encouragement. For patients who have a behavioral health disorder, intensive behavioral therapy with longer and more frequent sessions is often necessary.
Using motivational interviewing and the Five R's system can also be effective. This system is targeted at patients who use tobacco, and are not yet ready to quit. It can motivate change by helping them understand the importance of quitting in personal terms.
The Five R's
Relevance. Why is quitting relevant to this patient? For example, maybe he or she has had a personal health scare, such as a recent heart attack, or has a child who has asthma.
Risk. Ask the patient to list negative effects of their tobacco use. These may include short-term risks, long-term risks, and environmental damage.
Rewards. Ask the patient to list benefits of quitting. These may include being healthier, saving money, setting a good example, or having better self-esteem.
Roadblocks. Ask the patient to identify barriers to quitting. Then, talk about ways to address these barriers. For example, if a patient is worried about withdrawal symptoms, ease his or her fears by describing medication options that can help.
Repetition. The health care team should repeatedly follow up with the patient, keeping in mind that it may take repeated attempts to quit, especially for patients with a behavioral health disorder.32
Important Notes About Bupropion SR and Varenicline
Serious neuropsychiatric events (e.g., behavior changes, hostility, agitation, depressed mood, suicidal thoughts, or actions) have been reported by patients who use varenicline or bupropion SR for smoking cessation. Close follow up is recommended.
The FDA released a safety announcement regarding Chantix (varenicline) and its effects on users who drank alcohol during treatment with Chantix. The announcement states that some patients taking Chantix experienced decreased tolerance to alcohol, including increased drunkenness, unusual or aggressive behavior, or they had no memory of things that happened. The announcement also warned of rare accounts of seizures in patients treated with Chantix.36
Bupropion SR is contraindicated in patients who have a history of an eating disorder.
Seven first-line medications (5 nicotine and 2 non-nicotine) have been approved by the U.S. Food and Drug Administration (FDA), and reliably increase long-term smoking abstinence rates. These include:32
- Bupropion SR
- Nicotine gum
- Nicotine inhaler
- Nicotine lozenge
- Nicotine nasal spray
- Nicotine patch
Patients attempting to quit smoking should be encouraged to use appropriate medication, either alone or in certain combinations, unless use is contraindicated or the patient is in a specific population or there is insufficient evidence of effectiveness.32
Patients who have a behavioral health disorder are often highly nicotine dependent. Most will need medication to manage withdrawal symptoms, which will likely be more severe than those in the general population. It is very important to customize pharmacotherapy for these patients. For example, for patients who have a history of inhaling drugs, nicotine nasal spray is not recommended. For patients who have schizophrenia, the nicotine patch has been shown to be highly effective.37,38 Take into account a patient’s current medications, previous quit attempts, access to affordable medication, and personal preferences.
In particular, physicians need to carefully monitor the dosage and effects of psychiatric medications during quit attempts by patients who have a behavioral health disorder. Because smoking increases the metabolism of some medications, quitting can increase their effects. In addition, because ongoing use of nicotine may modulate psychiatric symptoms and medication side effects, changes in a patient’s smoking status require close follow up.
1 National Center for Chronic Disease Prevention and Health Promotion (U.S.) Office on Smoking and Health. The health consequences of smoking—50 years of progress: a report of the Surgeon General. Atlanta, GA. U.S. Dept. of Health and Human Services, Centers for Disease Control and Prevention(www.surgeongeneral.gove). 2014.
2 Substance Abuse and Mental Health Services Administration. The NSDUH report: adults with mental illness or substance use disorder account for 40 percent of all cigarettes smoked. Rockville, MD. U.S. Dept. of Health and Human Services. U.S. Public Health Service. 2013.
3 Centers for Disease Control and Prevention. Vital signs: current cigarette smoking among adults aged ≥ 18 years with mental illness—United States, 2009-2011. Morb Mortal Wkly Rep. 2013;62(5):81-87.
4 Maryland’s Tobacco Resource Center—Linking Professionals to Best Practices. Special populations—mental illness(mdquit.org). Accessed May 1, 2015.
5 Kalman D, Morissette SB, George TP. Co-morbidity of smoking in patients with psychiatric and substance use disorders. Am J Addict. 2005;14(2):106-123.
6 Hall SM, Prochaska JJ. Treatment of smokers with co-occurring disorders: emphasis on integration in mental health and addiction treatment settings. Annu Rev Clin Psychol. 2009;5:409-31.
7 Druss BG, Zhao L, Von Esenwein S, Morrato EH, Marcus SC. Understanding excess mortality in persons with mental illness: 17-year follow up of a nationally representative US survey. Med Care. 2011;49(6):599-604.
8 Sullivan MA, Covey LS. Current perspectives on smoking cessation among substance abusers. Curr Psychiatry Rep. 2002;4:388-96.
9 American Psychiatric Association. Diagnostic Criteria from DSM-IV. Washington, DC. 1994.
10 Dursun SM, Kutcher S. Smoking, nicotine and psychiatric disorders: evidence for therapeutic role, controversies and implications for future research. Med Hypotheses. 1999;52:101-109.
11 Kendler KS, Neale MC, MacLean CJ, Heath AC, Eaves LJ, Kessler RC. Smoking and major depression. A causal analysis. Arch Gen Psychiatry. 1993;50:36-43.
12 Ziedonis, DM, Kosten TR, Glazer WM, Frances RJ. Nicotine dependence and schizophrenia. Hosp Community Psychiatry. 1994;45:204-06.
13 Williams JM, Ziedonis DM. Addressing tobacco among individuals with a mental illness or an addiction. Addict Behav. 2004;29(6):1067-83.
14 Heishman SJ. Nicotine: pharmacology and addiction. Ther Drug Monit-Tox. 1999;20(9):223-38.
15 Heishman SJ, Taylor RC, Henningfield JE (1994). Nicotine and smoking: A review of effects on human performance. Exp Clin Psychopharmacol. 1994;2(4):345-95.
16 Zevin S, Benowitz, NL. Drug interactions with tobacco smoking. An update. Clin Pharmacokinet. 1999;36(6):425-38.
17 Kroon LA. Drug interactions with smoking. Am J Health System Pharm. 2007;64(18):1917-21.
18 Morris C, Waxmonsky J, May M, Giese A, Martin L. Smoking cessation for persons with mental illness. A toolkit for mental health providers(www.integration.samhsa.gov). 2009.
19 Holtzman A. Memo to Horace Kornegay about tax-free cigarettes for patient treatment. Tob Inst. 1975;TCAL0004383.
20 Robertson E. Hawaii State Hospital request to RJ Reynolds for cigarettes. 2000.
21 Torrey EF. Cigarette donation request for long-term psychiatric patients. 1980. Bates No. 502358650.
22 Prochaska JJ, Hall SM, Bero LA. Cigarette smoking among individuals with schizophrenia: what role has the tobacco industry played? Bull Schizophr. 2008;34:555-67.
23 Centers for Disease Control and Prevention. Physician and other health care professional counseling of smokers to quit—United States, 1991. Morb Mortal Wkly Rep. 1993;42(44):854-7.
24 Centers for Disease Control and Prevention. Quitting smoking among adults—United States, 2001-2010(cdc.gov). Morb Mortal Wkly Rep. 2011;60(44);1513-19.
25 Prochaska JJ, Fletcher L, Hall SE, Hall SM. Return to smoking following a smoke-free psychiatric hospitalization. Am J Addict. 2006;15:15-22.
26 Clarke JG, Stein MD, McGarry KA, Gogineni A. Interest in smoking cessation among injection drug users. Am J Addict. 2001;10:159-66.
27 Nahvi S, Richter K, Li X, Modali L, Arnsten J. Cigarette smoking and interest in quitting in methadone maintenance patients. Addict Behav. 2006;31:2127-34.
28 Richter KP, Gibson CA, Ahluwalia JS, Schmelzle KH. Tobacco use and quit attempts among methadone maintenance clients. Am J Public Health. 2001;91:296-99.
29 Rohsenow DJ, Monti PM, Colby SM, Gulliver SB, Swift RM, Abrams DB. Naltrexone treatment for alcoholics: effect on cigarette smoking rates. Nicotine Tob Res. 2003;5:231-36.
30 Zullino D, Besson J, Schnyder C. Stage of change of cigarette smoking in alcohol-dependent patients. Eur Addic. Res. 2000;6:84–90.
31 National Commission on Prevention Priorities. Preventive care: a national profile on use, disparities, and health benefits(www.prevent.org). Washington, DC. Partnership for Prevention. 2007.
32 Fiore MC, Jaen CR, Baker TB, et al. Treating tobacco use and dependence: 2008 update(www.ahrq.gov). Clinical practice guideline. Rockville, MD. U.S. Dept. of Health and Human Services. U.S. Public Health Service. 2008.
33 Agaku, IT, King BA, Dube SR. Centers for Disease Control and Prevention. Current smoking among adults—United States, 2005-2012(www.cdc.gov). Morb Mortal Wkly Rep. 2014;63(02)29-34.
34 Solbert LI, Maciosek MV, Edwards NM, Khanchandani HS, Goodman MJ. Repeated tobacco-use screening and intervention in clinical practice: health impact and cost effectiveness. Am J Prev Med. 2006;31(1):62-71.
35 Baird M, Blount A, Brungardt S, et al. Joint principles: integrating behavioral health care into the patient-centered medical home(www.annfammed.org). Ann Fam Med. 2014;12(2):183-85.
36 U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA updates label for stop smoking drug Chantix (varenicline) to include potential alcohol interaction, rare risk of seizures, and studies of side effects on mood, behavior, or thinking(www.fda.gov). U.S. Dept. of Health and Human Services. 2015.
37 Levin ED, Wilson W, Rose JE, McEvoy J. Nicotine-haloperidol interactions and cognitive performance in schizophrenics. Neuropsychopharmacology. 1996;15(5):429-36.
38 Adler LE, Olincy A, Waldo M, et al. Schizophrenia, sensory gating, and nicotinic receptors. Schizophr Bull. 1998;24(2):189–202.
The AAFP Multi-State Office Champions Behavioral Health Tobacco Cessation Project was supported by the Smoking Cessation Leadership Center.