Treating Tobacco Dependency & Mental Illness
words by susan preston / photograph by pete byron
ndividuals with schizophrenia are three times more likely to smoke than the general population. They have higher nicotine blood levels because their method of smoking provides them more nicotine per cigarette. Higher levels of nicotine in their system mean a greater dependence on tobacco. Quitting is far more difficult.
“For individuals with serious psychiatric problems, we haven’t really addressed the tobacco dependency problem,” says Jill Williams, MD, a psychiatrist and smoking addiction specialist. “In fact, smoking is often treated as a reward in psychiatric treatment facilities. If you’re judged to have been behaving well, you get to go outside for a smoke.” In February 2008, The Journal of the American Medical Association published a paper she authored calling on the U.S. public mental health system to make smoking cessation a bigger priority. Williams has been a passionate advocate for changing this paradigm for years.
Smoking poses significant health and life issues for individuals with schizophrenia. They have a 20 percent reduced life expectancy, in part because of smoking-related respiratory and cardiovascular diseases. Smoking also presents financial and social consequences. The double stigmas of mental illness and smoking can make it more difficult to find a job, housing and friends.
“Helping these individuals is quite a challenge,” Williams says. “First of all, they’re not usually motivated to quit. Secondly, their blood nicotine levels indicate a serious nicotine dependency. Thirdly, mental health professionals are not identifying and treating tobacco use in their patients.”
Her team conducted a study of the smoking habits of individuals with schizophrenia a few years ago. They compared this group to smokers without mental illness. The results showed that smokers with schizophrenia had 1.3 times more nicotine in their blood than the control group, even though participants in both groups smoked the same number of cigarettes. Researchers attributed the higher level to their finding that individuals with schizophrenia puff cigarettes in a way that allows them to get the most nicotine.
“Smoking is a self-medicating activity for these individuals,” she notes. “The nicotine activates cholinergic receptors that may be abnormal in schizophrenia, enhancing attention and concentration. But while nicotine may be beneficial, tobacco is not. Yet, we must take into account that for a smoking cessation approach to be effective for this population it must incorporate nicotine in some form — patches, nasal spray, inhalers, or gum — in addition to counseling.”
Right now, Williams is conducting a study comparing nicotine intake in smokers with schizophrenia to smokers with bipolar disorder and to smokers with no mental illness. She also is directing two clinical drug trials. One NIH-sponsored study is assessing the effectiveness of Selegiline, a drug currently used to treat Parkinson’s disease, as a treatment for smoking cessation. Thirty individuals have been recruited. Participants, who must have smoked at least 15 cigarettes within the past month and who have smoked for the past five years, have been divided into two groups. For nine weeks, one group will wear a Selegiline Transdermal Patch and the other a patch containing a placebo. Both groups will receive brief behavior intervention for the three months of the study. The researchers will follow up with each participant a year later. The second study will determine the effectiveness of Varenicline (Chantix) as an aid for smoking cessation in individuals with schizophrenia. Participants in this study must be motivated to quit, have smoked at least 15 cigarettes a day for the past year, and not been hospitalized for the past six months with a schizophrenic episode. They will be divided into two groups, one receiving Chantix and the other a placebo for 12 weeks. All participants will receive weekly counseling for the duration of the study. Chantix is manufactured by Pfizer, which is sponsoring the study.
In April, Williams and her colleagues are presenting several posters on their research at an international conference in Dublin. “The take-home message for our colleagues is that treating the tobacco dependency is as important as treating the mental illness,” Williams says. “When we do that, we give our patients the opportunity to lead healthier lives all around.”