Tobacco Use in Special Populations: Psychiatric and Substance Use Disorders

1. Tobacco Use in Special Populations: Psychiatric and Substance Use Disorders Eric Heiligenstein, M.D. Clinical Director, Psychiatry Service University Health Services Associate, CTRI University of Wisconsin-Madison

6. Tobacco Use Disparities Ethnic minorities Low SES Pregnant women Youth Coexisting psychiatric and substance use disorders

7. Objectives Identify disproportionate smoking rates among individual�s experiencing psychiatric disorders Understand the additive morbidity and mortality to individuals with psychiatric disorders Discuss integration of tobacco use identification and cessation efforts into mental health/substance abuse practices Understand the concurrent treatment needs of individuals with psychiatric disorders when they are treated for nicotine dependence

8. Association of Smoking and Psychiatric Disorders Rates among specific diagnoses General population 20.9% Panic disorder 35% Depression 49% Alcohol dependence 80% Schizophrenia/Bipolar Disorder 88% Hughes, 1986

9. Consume 45% of cigarettes smoked in U.SBreslau, 2003

10. Smoking Rates Compared to the Number of Lifetime Psychiatric Diagnoses

11. Smoking and Mental Health Problems in Treatment-Seeking University Students (n=503) Heavy smokers compared to light and non-smokers Poorer overall well-being Greater functional impairment More severe depression and anxiety Smoking is severity of illness multiplier

12. Additional Complications of Smoking and Psychiatric Disorders Additive mortality risks Heart disease is 7X higher than peers and more than 7x the suicide rate. Department of Mental Health, Massachusetts, 2001 Affects psychotropic blood levels Depressed smokers have higher suicide rates than depressed nonsmokers Bruce, 1994 Lohr, 1992 Yassa, 1987

13. Fundamental Problems: Smokers with Psychiatric Disorders Neurobiological factors reinforce use of nicotine Feel excluded from mainstream cessation programs Lower rate of quit attempts Higher tobacco relapse rates

14. Fundamental Problems: Smokers with Psychiatric Disorders Long considered part of psychiatric culture Clinicians believe they are not able/willing to quit For those with chronic psychiatric disorders Major part of daily routine/structure Alleviates stigma Positive/negative freedoms

15. Tobacco Use and Specific Psychiatric Disorders Major Depression (MDD) Anxiety Disorders Alcohol abuse/dependence Schizophrenia/Bipolar Disorder

16. Smoking and Specific Psychiatric Disorders Major Depression (MDD) Anxiety Disorders Alcohol abuse/dependence Schizophrenia/Bipolar Disorder

17. Link Between MDD and Smoking

18. Smoking and MDD Smokers with a past history of MDD More likely to have post-cessation MDD Risk greatest first 6 months post-cessation Leads to more severe nicotine withdrawal symptoms High risk for relapse in first week Female risk>male Quattorocki, 2000 Niaura, 1999 Hughes 2007

19. NRT and MDD NRT alone insufficient treatment for smokers with current/past MDD No effect on mood Cessations rates not improved Thorsteinsson, 2001 Smith, 2003

20. SRI�s and Smokers with MDD No benefit for smoking cessation Can offset negative moods during a quit attempt Can reduce likelihood of emergent depression during quit attempt Can be combined with Bupropion/NRT Can be combined with varenicline Cook, 2004 Chengappa, 2001 Smith, 2003

21. Bupropion and Smokers with MDD Can be used as monotherapy for both problems Can be combined with varenicline Treatment may need to be extended beyond traditional 3-6 months

22. Combined Treatments for Depressed Smokers Adding CBT to standard treatments show mixed results No research available for other types of non-pharmacological interventions Brown, 2007 Hall, 2006

23. Smoking and Specific Psychiatric Disorders Major Depression (MDD) Anxiety Disorders Alcohol abuse/dependence Schizophrenia/Bipolar Disorder

24. Smoking and Anxiety Disorders Smokers have greater anxiety and panic symptoms than non-smokers Heavy smoking in adolescence associated with higher risk of developing Agoraphobia GAD Panic disorder Increased risk for relapse during early stages of quit attempt Breslau, 2004 Amering, 1999

25. SRI�s and Smokers with Anxiety Disorders No benefit for smoking cessation Can reduce likelihood of emergent anxiety or panic during quit attempt BUP not appropriate as only medication Carefully combined with Bupropion/NRT Can be combined with varenicline

26. Smoking Cessation and PTSD Cessation not associated with worsening of PTSD symptoms Integration into standard care improves quit rates BUP tolerated and effective treatment McFall, 2006 Hertzberg, 2001

27. Smoking and Specific Psychiatric Disorders Major Depression (MDD) Anxiety Disorders Alcohol abuse/dependence Schizophrenia/Bipolar Disorder

28. Smoking and Alcohol Use Individuals are three times as likely to smoke if they binge drink Consumption of alcohol Increases length of time smoking Increases number of puffs Increases subjective smoking satisfaction Dawson, 2000

30. Smoking and Alcohol Dependence Over 72% of alcoholics are heavy smokers (9% of general pop.) Increased urge to drink among alcoholic smokers when they smell cigarettes Dawson, 2000

31. Alcohol Dependence and Smoking Appears to compound alcohol-induced neuronal injury Continued smoking diminishes recuperation from alcohol-related cognitive deficits during alcohol abstinence

32. Perfusion images of nonsmoking light drinker (nsLD) and smoking alcoholic (sALC)

34. Cessation Treatment for Alcohol Users Standard cessation treatments are effective No evidence of increased use of other substances during cessation treatment Alcohol abstinence days greatest for those who quit smoking Saxon, 2003 Kohn, 2003

35. Barriers to Tobacco Dependence Treatment in Substance Treatment Facilities 38% thought best time to treat was when patient wanted treatment 14% believed their patients benefited from smoking 25% had advised patients to delay quitting smoking

36. Smoking and Specific Psychiatric Disorders Major Depression (MDD) Anxiety Disorders Alcohol abuse/dependence Schizophrenia/Bipolar Disorder

37. Smoking and Schizophrenia/Bipolar Disorder Highest smoking rates than any other patient group Smoke 10 billion pack per year More per day Prefer high tar, high nicotine Smoke to ends of cigarettes D�Mello, 2001

38. Smoking Cessation for Schizophrenia/Bipolar Disorder Have lower cessation rates than general population Cognitive deficits may contribute to cessation treatment failure Traditional cessation treatments may be inadequate Harm reduction and NRT Hospitalization may be unique opportunities to initiate treatment

39. BUP for Smoking Cessation in Schizophrenia Can lead to smoking reduction Quit rates comparable to general population and durable Quit rates enhanced with CBT Overall symptoms not worsened Evins, 2004, 2005 Fatemi, 2005 George, 2002

41. Mental Health Benefits From Treating Tobacco Dependence Emerging evidence that morbidity is reduced May enhance abstinence from substances Reduced financial burden Increased self-confidence

42. Necessary Mental Health Care System Interventions Systematic identification processes that mesh with a non-medical practice style Educational efforts for providers that emphasize the detrimental effects of smoking on mental health Integration of cessation efforts with primary mental health treatments Address emotional/behavioral comorbidity that effect cessation efforts in primary care settings

44. Contact Information Eric Heiligenstein, M.D. elheilig@wisc.edu 608-262-9199

45. Brief Screening for Depression in Smokers Have you been consistently depressed, most of the day, nearly every day, for the past 2 weeks? In the past 2 weeks have you been less interested in most things or less able to enjoy things?

46. Brief Screening for Anxiety in Smokers Do you worry continually almost every day about both big and small problems, situations, events, and/or activities? Does your worrying interfere with your normal routines, work or school, and/or social activities?

47. Brief Screening for Problematic Alcohol Use in Smokers Do you sometimes drink alcoholic beverages? How many times in the past years have you had 5/4 or more drinks in a day? On average, how many drinks per week do you have?