that the impact of quitting is also dramatic. If you quit before
35, you gain back a whole decade of life expectancy and even if
you quit in late middle age, you gain back five or six years.”
Questions remain, however, about how best to help smokers
with mental illnesses. More than 8,700 articles informed the
U.S. Department of Health and Human Services Clinical
Practice Guidelines for treating tobacco, Prochaska notes, and
fewer than 30 of those focused on people with current mental
illness or addictive disorders. “There’s still a lot of science that
needs to occur to show how we can maximize treatment effects
of quitting smoking — what’s most acceptable, most efficacious,
most tolerable and safest,” she says.
Some research suggests tobacco treatment may be most
effective when folded into other mental health care. In 2010,
Miles McFall, PhD, at the University of Washington, Seattle,
and colleagues reported in JAMA that when smoking cessation
was integrated into treatment for veterans with post-traumatic
stress disorder, the patients were more likely to be smoke-free
18 months later when compared with patients who attended
smoking-cessation clinics separate from their PTSD treatment.
Removing temptation is also important, says Jill Williams,
MD, who directs the addiction psychiatry division at the Robert
Wood Johnson Medical School of the University of Medicine
and Dentistry of New Jersey. Making mental health facilities
smoke-free would be a big step in the right direction. “People
are more successful in quitting when there are restricted
smoking policies in their environment,” she says.
Yet the move to ban smoking in psychiatric hospitals and
treatment centers has been surprisingly slow. “A lot of hospitals
are now smoke-free, which is even better than it was 10 years
ago,” Williams says. However, most outpatient sites still allow
tobacco use. “Patients typically are still allowed smoke breaks
and can go right outside of the building to smoke,” she adds.
An environment that permits and even encourages smoking
is just one example of the ways this population of smokers
has been overlooked, Williams says, and it’s long past time
for the health-care system to reach out and help. “There are
resources available for tobacco cessation, and almost none are
being directed to this population,” she says. “It really has to be a
A helping hand
Gradually, health-care practitioners are becoming aware of the
issue of smoking among mental health patients, says McAfee.
He points out that 20 years ago, primary-care physicians
and cardiologists viewed smoking as outside their scope
of practice. But as more and more patients developed lung
cancer or suffered heart attacks, physicians realized “they
weren’t doing their patients any favors by ignoring
tobacco status,” he says.
today are finally
having the same
realization, he adds. “I think we’re almost at the beginning of a
paradigm shift in mental health treatment.”
Even as researchers continue to find the best ways to target
this population, behavioral health-care providers can go a long
way toward helping their patients quit, Prochaska says. Along
with Karen Hudmon, DrPH, MS, RPh, a professor of pharmacy
at Purdue University, Prochaska has helped develop curricula
to train health professionals to help all patients (including
those with mental illness) give up tobacco. The program, Rx
for Change: Clinician-Assisted Tobacco Cessation, is available
online at http://rxforchange.ucsf.edu.
When treating smokers with mental disorders, experts note,
it’s important to pay close attention to the medications they
are taking. Fortunately, nicotine-replacement therapy doesn’t
interfere with antidepressants or antipsychotics, Prochaska says,
and is often a great resource to help patients quit.
However, smoke itself can alter the levels of psychiatric
medications in the bloodstream. Tars in cigarette smoke affect
the rate at which the liver metabolizes certain medications,
causing blood levels of antidepressants and antipsychotics to
decline. If a patient quits smoking, blood levels rise and his
or her old dose can become toxic. “What looks like symptoms
getting worse when people quit smoking can often be
medication side effects,” says Morris. “Providers need to assess
for potential medication toxicity and adjust medication dosages
Often, patients with mental illness have been smoking more
years, and more cigarettes per day, than smokers in the general
population. As a result, they may need more intensive treatment
to help them quit. “People with mental illnesses may benefit
from longer duration of treatment,” says McAfee.
Still, Morris says, therapists can help these patients by using
the same tools they would use for any other smoker: group
therapy, individual therapy and motivational interviewing, for
instance. “You treat these populations pretty much just like
you’d treat the general population,” he says.
Ultimately, he adds, there’s no excuse for not helping
patients end their dependence on tobacco. “These individuals
want to quit, they can quit and providers in the behavioral
health-care system have the best skill sets to help them,” he says.
“Psychologists are a key to this.” n
Kirsten Weir is a writer in Minneapolis.