Health.vic.gov.au

Smoking reduction and cessation
for people with schizophrenia
for general practitioners
These Guidelines are the result of a collaborative enterprise between SANE Australia and the
University of Melbourne Department of Psychiatry, funded by the Victorian Department of
Human Services Victoria and Quit Victoria. Author: Dr Kathryn M Strasser, 2001
1 IntroductionIn Australia, tobacco smoking is the largest single preventable cause of death and disease(Ridolfo 2001). One in two lifetime smokers will die from diseases caused by tobacco, and halfof these deaths will occur in middle age. Smoking cessation is the most cost-effectiveintervention a general practitioner can provide (Eddy 1992).
Smoking cessation programs have had some success in the general population but until recentlysmoking in people with schizophrenia has been a neglected area. People with schizophreniaare rarely encouraged to stop, or given support, in their efforts to quit (Addington 1998).
Recent research has found that the majority of these people are interested in quitting(Addington 1997) and that stopping smoking is possible for people with schizophrenia,especially if the treatment is specifically designed for them (Addington 1998).
SANE Australia is an independent national organisation committed to improve the wellbeing ofAustralians seriously affected by mental illness. SANE Australia has developed The SANESmokeFree Kit which includes a smoking reduction and cessation program for use by healthworkers that is designed to address the needs of people with a mental illness. Initial evaluationof this program has shown that the outcome is significantly enhanced when there isparticipation of the person’s doctor.
This booklet aims to inform general practitioners regarding the extent of the problem, thenature of the problem and ways to assist people with schizophrenia cease or at least reducetheir smoking. While intended to be used in conjunction with patient participation in asmoking reduction and cessation program, it may also be helpful in other situations.
2 Prevalence of smoking in schizophreniaThe prevalence of smoking in schizophrenia may be as high as 90% (Glassman 1993). This is instark contrast to the prevalence in the general population, which is now just over 20% (1999).
People with schizophrenia tend to smoke more cigarettes per day (average 40 cigarettes) andsmoke brands of cigarettes which have high levels of nicotine and tar, which means theyconsume up to three times more nicotine than the average Australian smoker (CommonwealthDepartment of Human Services and Health 1994).
Smoking Cessation and Schizophrenia: Guidelines for GPs Biological
1 Improves cognitionNicotine increases alertness by stimulating the dopaminergic pathways to the prefrontalcortex. This enhances concentration, information processing and learning which is of benefit topeople with schizophrenia, in whom cognitive dysfunction may be part of their illness or a sideeffect of antipsychotic medication (Levin 1996).
2 Aids relaxationNicotine is an unusual drug as it can cause both stimulation and relaxation. Nicotine can reduceanxiety, tension and other unpleasant emotions such as anger. People with schizophrenia mayhave particular difficulties dealing with stressful situations and negative feelings and nicotinemay help with this.
3 Possible antidepressant effectThere is a strong association between smoking and depression, and depression can occur inmany people with schizophrenia (estimates vary from 10% to 70%). Nicotine withdrawal canprovoke the onset of major depression (Glassman 1993). Nicotine may have an antidepressanteffect by its effect on various neurotransmitter systems.
4 Modification of psychotic symptomsThe negative (deficit) symptoms of schizophrenia, such as lack of motivation, lack of energy,and affective blunting, are thought to be due to decreased dopamine activity in the prefrontalcortex. Nicotine may reduce these negative symptoms by augmenting dopamine release in theseareas (Glassman 1993).
Nicotine affects some processing of incoming sensory information (Adler 1993), which inschizophrenia may lead to a decrease in positive symptoms such as auditory hallucinations, atleast in the short term.
5 Modification of side-effects of antipsychotic medicationThere is some evidence to suggest that smoking is associated with a reduced incidence ofantipsychotic induced Parkinsonism (Goff 1992).
Psychosocial
1 Relief of boredomBoredom can be a major problem for people suffering with schizophrenia. Smoking can helpprovide a framework for the day.
2 Social currencySmoking can facilitate social interaction especially for people with negative symptoms. As oneman with schizophrenia has said, ‘Smoking is a language you can speak even when you arecrazy’ (Champ 1996).
Smoking Cessation and Schizophrenia: Guidelines for GPs Biological
1 Physical diseasePeople with schizophrenia have higher mortality rates than control populations even aftertaking suicide into account. In particular, rates of cardiovascular and respiratory disease arehigher than those of age-matched controls (Allebeck 1986 & Ruschena 1998). Smoking isbelieved to be a major contributing factor to these elevated rates.
2 Increased doses of antipsychotic medicationHydrocarbons of tar in cigarettes induce liver enzymes, which increase the metabolism of someantipsychotics (Lohr 1992), resulting in higher doses being required to achieve clinical results inpeople who smoke.
3 Increased side-effects of antipsychotic medicationSome studies have shown an increase prevalence of dyskinetic movements in smokers,including the restlessness of akathisia and the slower involuntary movements of tardivedyskinesia (Goff 1992).
4 Risk of additional substance abuseAbuse of one drug class may reinforce abuse of other agents, such as caffeine, alcohol andcannabis (Buckley 1998).
Psychosocial
1 FinancialPeople with schizophrenia often have limited incomes. Smokers can spend one third or more oftheir money on cigarettes (a packet of 25 cigarettes costs approximately $9). This leaves littlefor basic items such as food and accommodation, and even less for recreational activities.
2 Restriction of activitiesMost venues now have smoking bans which means heavy smokers find it difficult to participatein various activities, including recreation (for example, going to the cinema), education (forexample, attending vocational courses) and work.
3 Physical appearanceHeavy smoking adversely affects appearance, for example stained fingers and teeth, smokingodour and lined skin. These factors increase barriers to socialising or getting work.
Smoking Cessation and Schizophrenia: Guidelines for GPs 4 Readiness to quitChanging habits, especially where there is physical addiction involved, is notoriously difficult.
This is at least as true for people with schizophrenia who smoke, as it is for the rest of us.
Prochaska and DiClemente’s stage of change model (Prochaska and DiClemente 1983)illustrated below is useful in that it recognises that nicotine dependence is a chronic relapsingdisorder, with most smokers requiring five to seven attempts before they finally quit for good.
Many patients do not realise it usually takes several attempts to stop smoking, and they willneed to be re-motivated to attempt to quit if they have been unsuccessful in the past. It is usefulto think of smoking cessation as a process rather than an event.
Once a person has been identified as a smoker, his or her state of readiness to quit can bedetermined. This is important because smokers who are not considering quitting appear toneed different interventions than those who are ambivalent about stopping or those presentlyinterested in stopping (APA 1996).
Smokers in the pre-contemplation stage (not considering quitting) can be helped to move tocontemplation of quitting. This can be done by considering the negative consequences ofsmoking for them, barriers to quitting and the advantages of smoking cessation for thatindividual (the information needs to be personalised). It is worthwhile to actively encouragequitting and offer support and treatment, as well as conveying the message that having apsychiatric illness such as schizophrenia is not a reason not to make a quit attempt.
Smoking Cessation and Schizophrenia: Guidelines for GPs 5.1 Identify smokersRegular inquiry regarding smoking status is important.
5.2 Assess readiness to quitAscertain the patient’s level of motivation to quit by seeing where they are along the stage ofchange model. With the patient, determine the costs and the benefits of smoking for thatperson.
A smoking history needs to be obtained, including number of cigarettes smoked currently, andpast usage. Up to 80% of smokers have tried to stop previously. The patient’s experience aboutthese attempts needs to be assessed including: • Any change in psychiatric functioning when he or she tried to stop • Cause of relapse (for example, due to withdrawal symptoms or exacerbation of • How long he or she remained abstinent • Prior treatment in terms of type, adequacy (dose, duration), compliance and patient’s • Expectations about future treatments.
5.3 Assess risks of smoking cessation Psychotic relapse
Smoking cessation may be associated with a risk of relapse of schizophrenia (Dalack 1996), so
it is important to be aware of the usual signs of relapse in that patient – for example, becoming
increasingly paranoid or behaving inappropriately.
Depression
Smoking cessation also carries the risk of precipitating a depressive disorder (Glassman 1993).
Current depressive illness needs to be recognised (for example, by using a screening instrument
such as the CES-D: see appendix 1) and, if present, treated before smoking cessation is
attempted. Any family history or past history of depressive illness and the subsequent
treatment needs to be noted. Buproprion (Zyban) is an antidepressant that is now used for
smoking cessation in the general population but is unsuitable for routine use in people with
schizophrenia as it may precipitate or exacerbate psychosis.
Smoking Cessation and Schizophrenia: Guidelines for GPs Change in medication effects
The tar in cigarette smoke induces certain liver enzymes (CYP 1A2) resulting in increased
metabolism of some antipsychotics. Smokers thus require larger doses of these antipsychotics
for treatment. When their smoking status changes, this may affect the dose of antipsychotic
required. It is important to document the current psychiatric medication and the presence of
any side effects prior to smoking cessation. The side effects include sedation and movement
abnormalities (extrapyramidal signs, akathisia).
Antipsychotic medications whose metabolism is definitely affected by smoking include: Antipsychotic medications whose metabolism appears not to be affected by smoking include: 5.4 Write an individual planSmoking reduction or cessation is best attempted when the person is psychiatrically stable.
People with schizophrenia may have cognitive deficits, so it is very important to write a plan,which they can take with them and refer to frequently.
5.5 Use nicotine replacementMost established smokers are nicotine dependent and thus will experience withdrawalsymptoms following smoking cessation. Nicotine withdrawal symptoms, such as anxiety,depression, insomnia, irritability, restlessness and weight gain, can be confused with, orexacerbate, the symptoms of schizophrenia. The use of nicotine replacement therapy (NRT)can substantially reduce but not eliminate these symptoms (Ziedonis 1997).
Nicotine replacement therapy (NRT) has been shown to increase quit rates and is consideredby some (Ziedonis 1997) to be an essential ingredient in smoking cessation programs forpeople with schizophrenia. There are few contraindications to its use, as it has little abusepotential and is not a cardiovascular risk as originally thought (Benowitz 1997). The role ofNRT needs to be discussed with the patient as many smokers do not realise that they arephysically dependent on nicotine.
Nicotine patches are usually the NRT of choice, however there may be reasons to choose thegum. Some studies have shown increased quit rates with the addition of ad-lib 2mg nicotinegum (APA 1996). If nicotine gum is used, education about proper use of the gum is important.
The recommended total duration of NRT is six to twelve weeks. Further information regardingchoice of NRT is contained in appendix 2.
Research and development of non-nicotine pharmacotherapy for smoking cessation continuesas there are a significant number of people who continue to smoke despite NRT. Bupropion(Zyban) is a selective noradrenergic and dopaminergic reuptake inhibitor that has recentlybecome available as a smoking cessation aid. The use of this medication is, however,complicated in the case of people with schizophrenia. There are pharmacodynamic reasons tobelieve it could precipitate or exacerbate psychosis, and many neuropsychiatric side-effects dooccur with the drug. Additionally there are pharmacokinetic interactions with antipsychotics, Smoking Cessation and Schizophrenia: Guidelines for GPs and a potential additive effect with other medications that could increase the risk of seizures.
Bupropion should only be used with care and caution in people with schizophrenia, with thepatient and prescriber both being aware of these potential problems, and with appropriatemonitoring.
5.6 Recommend group supportThe effectiveness of all forms of NRT is enhanced when accompanied by problem solving/skillstraining. Participation in a quit group is a useful way of people learning cognitive-behaviouraltechniques that will aid smoking reduction and cessation maintenance. As people withschizophrenia may have associated cognitive, affective and social difficulties, a speciallydesigned program, such as the SANE SmokeFree Program, is preferable.
The SANE SmokeFree Program contains 10 group sessions and is run by two trainedfacilitators. The content of the sessions include: Introduction to the ProgramReasons to quit Understanding why we smokeWays of quitting 5.7 Monitor frequentlyWhen a management plan for smoking cessation has been formulated by the generalpractitioner and the patient, a quit day should be planned. The patient should be seen one tothree days after smoking cessation to monitor withdrawal symptoms and any other difficulties,as well as providing encouragement and support. Waiting a week to see a patient isunsatisfactory, as 65% of patients will have relapsed by then (Hughes 1995).
After initial monitoring, it is recommended that patients be monitored weekly for the first fourweeks to watch for signs of psychotic relapse, onset of depressive illness and need to changemedication levels (for example, lower antipsychotic medication if increased side effectsapparent). Thereafter, monthly review is suggested for approximately six months.
5.8 Congratulate on any progressAs mentioned earlier, nicotine dependence is a chronic relapsing disorder. People need to beencouraged to value any progress in their efforts to stop smoking, and be supported in futureattempts. People with schizophrenia report enormous sense of satisfaction after they havesuccessfully quit, as illustrated by this statement, ‘I have experienced a wonderful freedom sincequitting. I now feel more in control of my life and as a result have been able to make otherlifestyle changes’ (Champ 1996).
A summary of these management guidelines can be found in appendix 3 and an initialassessment and review form in Appendix 4.
Smoking Cessation and Schizophrenia: Guidelines for GPs 6 ConclusionSmoking is extremely common among people with schizophrenia and causes significant healthand lifestyle problems. People with schizophrenia often find it very difficult to quit. As well asthe usual problems with nicotine dependence, nicotine may alleviate some of their psychiatricsymptoms and side effects of medication. If they do stop smoking, the effect of smokingcessation on their psychiatric illness and medication, as well as the risk of depression, needsto be monitored. Despite these problems, recent research suggests that, with the use ofnicotine replacement therapy and specially designed cognitive-behavioural based groupsupport, people with schizophrenia can effectively be helped to become more motivatedtowards smoking reduction and progress towards smoking reduction and even cessation.
7 Other resources
SANE Australia
SANE Smokefree Project Coordinator
(03) 9682 5933
QUIT Victoria
Ms Pat Kee, Services Manager
or
Ms Linda Steel, Services Project Coordinator
(03) 9663 7777
Smoking Cessation and Schizophrenia: Guidelines for GPs Addington, J., el-Guebaly, N., Addington, D., Hodgins, D. Readiness to stop smoking in schizophrenia. Canadian Journal of Psychiatry, 1997; 42:49-52.
Addington, J. Group treatment for smoking cessation among persons with schizophrenia. Psychiatric Services, 1998; Allbeck, P., Wistedt, B. Mortality in schizophrenia. Archives of General Psychiatry, 1986; 43:650-653.
American Psychiatric Association. Practice guidelines for the treatment of patients with nicotine dependence.
American Journal of Psychiatry, 1996; October Supplement, 1-31 Benowitz, N.L. Treating tobacco addiction – Nicotine or no nicotine? The New England Journal of Medicine, 1997; Buckley, P.F. Substance abuse in schizophrenia: A review. Journal of Clinical Psychiatry, 1998; 59(supp3) :26-30.
Dalack, G.W., Meador-Woodruff, J.H. Smoking, smoking withdrawal and schizophrenia: Case reports and a review of the literature. Schizophrenia Research, 1996; 22:133-141.
Eddy, D, David Eddy Ranks the Tests, Harvard Health Letter , July 1992.
Glassman, A.H. Cigarette smoking: Implications for psychiatric illness. American Journal of Psychiatry, 1993; 150:546-553.
Goff, D.C., Henderson, D.C., Amico, E. Cigarette smoking in schizophrenia: Relationship to psychopathology and medication side effects. American Journal of Psychiatry, 1992; 149:1189-1194.
Hughes, J.R., Frances, R.J. How to help psychiatric patients to stop smoking. Psychiatric Services, 1995; 46:435-445.
Levin, E.D., Wilson, W., Rose, J.E., McEvoy, J. Nicotine-Haloperidol interactions and cognitive performance in schizophrenics. Neuropsychopharmacology, 1996;15:429-436.
Lohr, J.B., Flynn, K. Smoking and schizophrenia. Schizophrenia Research, 1992;8:93-102.
Polgar, S., McGartland, M. Social implications of current cessation measures and new program developments. In Mental Illness and smoking cessation: An urgent public health issue. Forum proceedings November 1996. Eds.
Hocking, B., Watt, J.
Prochaska, J.O., & DiClemente, C.C. Stages and processes of self-change of smoking: Towards an integrative model of change. Journal of Consulting and Clinical Psychology . 1983; 51:390-395.
Ridolfo B & Stevenson C 2001, The Quantification of Drug-caused Morbidity and Mortality in Australia 1998. Australian Institute of Health and Welfare, Canberra.
Ruschana D, Mullen PE, Burgess P et al. Sudden death in psychiatric patients. British Journal of Psychiatry, 1998; 172:331- Ziedonis, D.M., George, T.P. Schizophrenia and nicotine use: Report of a pilot smoking cessation program and review of neurobiological and clinical issues. Schizophrenia Bulletin, 1997; 23:247-254.
Smoking Cessation and Schizophrenia: Guidelines for GPs CES - D
Depression Rating Scale
Checklist for depressive symptomsCircle the score (0, 1, 2, or 3) for each statement that best describes how often you felt this way during the past week.
I was bothered by things that usually don’t I did not feel like eating; my appetite was poor I felt that I could not shake off the blues even I felt that I was just as good as other people I had trouble keeping my mind on what I was I felt that everything I did was an effort For GP: Note reverse scoring for items 4, 8, 12 and 16 Diagnostic decisions need to be backed up by clinical interview.
Smoking Cessation and Schizophrenia: Guidelines for GPs 24-hour Patch
smokers .(who may have been woken by cravings).
• RecommendationPreferred form of NRT for patients who do not experience side effects.
16 hour Patch
Avoids the vivid dream side effect of the RecommendationGood for moderately heavy smokers (>20/7) who cannot tolerate 24-hour patch side-effects.
Allows patient to regulate nicotine dose.
consumed 15 minutes before orafter using gum (need alkaline pHfor nicotine to be absorbed inbuccal mucosa). This can be aproblem when patients consume alot of caffeine (eg. in coffee orcoca-cola).
RecommendationRecommended for patients who can manage instructions for use, and for patients who need to mimic the nicotine 'highs and lows' ofsmoking.
• Allows patient to regulate nicotine dose.
• Offers a behavioural intervention.
RecommendationRecommended for patients weaning off 4mg gum.
Combination therapy
• Allows for higher nicotine dosing for heavily • Overcomes the lack of 'behavioural' aspects of RecommendationRecommended for patients who can manage instructions for use and cost.
Nicotine inhaler
Allows patient to regulate nicotine dose.
Involves a behavioural component similar to irritation, which diminish overtime.
RecommendationRecommended for patients who require additional behavioural interventions.
Smoking Cessation and Schizophrenia: Guidelines for GPs Appendix 3
Identify smokers
Assess readiness to quit
If not ready, find a personalised reason to quit.
Take a smoking history.
Assess risks of smoking
cessation
Depression.
Know if past history or family history.
Change in medication effects.
Know patient's current side effects, if any.
Write an individual plan
If psychiatrically stable, a written plan is important ascognitive deficits may be present.
Use nicotine replacement
Significantly increases quit rates and minimiseswithdrawal symptoms.
Recommend group support
Monitor frequently
See 1-3 days after quitting: deal with any problems.
See weekly for one month: assess for psychotic relapseand/or depression, and medication effects.
See monthly for six months: continue to monitormental state and medication.
Congratulate on any progress
Smoking Cessation and Schizophrenia: Guidelines for GPs Appendix 4
Smoking cessation and schizophreniaAssessment formUse in conjunction with the Management Guide Summary Patient details
Initial assessment
1 Assess readiness to quit (circle)
Precontemplation
Number of cigarettes currently smoked per day 2 Assess current state
3 Assess risks of smoking cessation
i Psychotic relapse (know usual signs of relapse in this patient)
ii Risk of depression
If YES to Current depression, treat depression prior to smoking cessation. Smoking Cessation and Schizophrenia: Guidelines for GPs Appendix 4
iii Risk of change in medication levels and effectiveness
Review current medication and consider pharmacology of current prescribed and other medication.
iv Risk of worsening medication side-effects.
Consider 3iii (above) and current side-effects such as sedation, akathisia, parkinsonism.
4 Use nicotine replacement therapy (NRT)
5 Recommend group support
6 Comments
Smoking Cessation and Schizophrenia: Guidelines for GPs Appendix 4
Smoking cessation and schizophrenia
Review form I first month
Appointment 1 (Three days after quit date)
Make subsequent appointments every week for four weeks.
Use the table below to record key information, as well as making any clinical notes indicated in your standard format. Appointment 2
Appointment 3
Smoking Cessation and Schizophrenia: Guidelines for GPs Appendix 4
Appointment 4
Appointment 5
Congratulate on any success
If not successful, consider reasons for relapse.
Smoking Cessation and Schizophrenia: Guidelines for GPs

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