Conversation Regarding Smoking Cessation (2007)

From Barbara

How can the recovery from tobacco dependence and recovery from a mental illness be linked? Tobacco does not contribute to mental illness. I understand it would be great for self confidence to have success with quitting but other than that I see no link. There are cases that show that nicotine actually helps to organize the thought process of persons with Schizophrenia. Yes-smoking does have risks but so do the medications we prescribe. I agree we should educate our clients but it should be their choice to quit and when. The program mentioned below (see bullet) allows people to attend without a quit date or even a promise in the future. That is the way to go. They state they were successful. I believe we would also be successful and protect the therapeutic, trusting relationships we have worked so hard to build

  • “Clinical Case Conference:
    Successful Tobacco Dependence Treatment in Schizophrenia

    Am J Psychiatry, Feb 2007; 164: 222 - 227.

    Jill M. Williams and Jonathan Foulds

    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)...

    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...

    In summary, this case demonstrates that intensive and sustained pharmacotherapy and psychosocial treatment can help smokers with schizophrenia to quit using tobacco and to go on to lead healthier lives without a worsening of mental health. Recovery from tobacco dependence is an important part of recovery from mental illness.

    Source: Am J Psych”

From David

Barbara, great inquiries. Even though your questions are not aimed at me let me try to articulate my thoughts on this issue. I suspect many staff here at Riverview have similar concerns and questions that you do. So please let me share what I have learned on this issue.

People with mental illness, due to the mental illness, (in part of the short term therapeutic effect that you refer to) have a predisposition to tobacco addiction. Thus, it is a part of the mental illness “syndrome”.

Although roughly 22% of the general population currently use tobacco products, approximately 75% of person’s with serious mental illness are dependent of tobacco product consumption, (85% to 95% of persons with schizophrenia a in state hospitals smoke). Persons with a diagnosis of schizophrenia are twice to three times more likely to die from cardiovascular disease, repertory disease and lung cancer. This contributes to a shorter life expectancy of 25 years . Although roughly 1.5%-2% of the general population are affected by schizophrenia, and 4.5 % have a serious mental illness, and 24% a diagnosable mental illness in the course of their life, 50% of all lung cancer deaths in America involve a person with a serious mental illness.

State hospitals found that patients who don’t smoke, that 26% saw patients threaten other patients and 21% reported witnessing staff coerce clients with cigarettes. Unarguably, the effects of allowing smoking in public psychiatric hospitals affects go beyond those who actually smoke. Also indicated in the literature, (Parks and 2006) is that, “Most individuals in recovery [from psychiatric illness] want to quit smoking, largely due to the cost of cigarettes, and for health reasons as well.” Research also shows that persons with mental illness who smoke want to quit at the same rate and for the same reasons as persons without mental illness who smoke.

Person’s with serious and persistent mental illness are much less likely to be offered smoking cessation interventions then members of other groups. Pre-conceived ideas on the ability of the mentally ill smoker may inhibit appropriate counseling of the smoking patient. Despite no empirical evidence in the literature that capacity to change health related behavior is different for persons with mental illness as compared to the general population, policy reform has left this population to practices long ago given up in other health and service delivery settings. For perspective on the width of the divide in public policy, consider that smoking is not allowed in Prisons in Maine to Montana, nor in restaurants from California to New York, nor bars in Minnesota to Hawaii. Yet as of the fall of 2006, 59% of State Psychiatric Hospitals continued to allow and in many cases promote this addictive behavior that is more likely to kill persons served then their mental illness. Predictions of failure or negative complication of service providers have been shown to be a deterrent to improvements in therapeutic milieus through policy reform.

The available information suggests there has been no rise in PRN use, AMA discharges, seclusion or restraint associated with smoking bans in psychiatric hospitals. About half of the state psych hospitals who allow smoking are planning on policy changes within the next year. “Concerns are cited by these facilities about going smoke free include resistance and opposition from staff who smoke, staff fear of patients’ reactions, fear of advocate’s reactions and fear of change, in general”, (NASMHPD Report 2006).

The “link” between smoking recovery and mental illness recovery is that health is interdependent on mind and body. They are not separate entities. Recovery is hard work and it is harder if you have a major physical illness and a major mental illness. It is even harder if you are dead.

Sincerely thanks for the opportunity to share in a dialogue about this important Riverview issue. I hope you have an opportunity to discuss more with persons you work with as to what the facts and challenges are about treating those we serve.

David S. Proffitt