GIM Primary Care Conference Presentation October 25, 2006

1. University of Wisconsin School of Medicine and Public Health Center for Tobacco Research and Intervention Psychiatric Morbidity and Smoking Cessation Stevens S. Smith, Ph.D. Assistant Professor / Licensed Psychologist Department of Medicine University of Wisconsin School of Medicine and Public Health Center for Tobacco Research and Intervention GIM Primary Care Conference Presentation October 25, 2006

2. Disclosure Statement • SmithKline Beecham • GlaxoSmithKline • Elan Corporation, plc I have received research support (but no consulting or speaking fees) from the following companies that market smoking cessation medications:

3. Learning Objectives Psychiatric morbidity and cessation in two case studies Influence of psychiatric morbidity on smoking cessation Evidence-based cessation treatment for smokers with psychiatric disorders

4. Case Studies

5. Case Studies

6. Case Studies: Smoking History

7. Progress: Dramatic Decrease in Adult Smoking Prevalence Over 40 Years 19652005 Number PercentNumber Percent Current 50 million 42.4% 47 million 20.9% Former 16 million 13.6% 51 million 21.5% Never 52 million 44.0% 135 million 57.6% (Source: National Health Interview Surveys, 1965-2005)

8. 42.4% 20.9%

9. Remaining Challenges • > 400,000 deaths per year nationally (8000 in WI) • 2,000 children and adolescents become regular smokers each day • $75 billion in added healthcare costs • $80 billion in lost productivity • Low rates of clinical assistance with quitting

10. 2003 Wisconsin Tobacco Survey Long-term success rate of “cold turkey” method is about 5%

11. Disproportionate Smoking Rates The highest rates of smoking are seen in individuals : • living below the poverty level • with the least education • working in blue-collar and service jobs • with psychiatric and substance use disorders

12. Tobacco Dependence and Mental Illness • Individuals with mental disorders typically smoke more cigarettes per day and they have greater difficulty quitting smoking • Individuals with a current psychiatric disorder currently make up about 30% of the population but consume 46% percent of all cigarettes smoked inthe U.S.

13. Smoking Status and Mental Illness: The National Comorbidity Survey (Source: Lasser et al., JAMA. 2000;284:2606-2610)

14. Smoking Status and Mental Illness: The National Comorbidity Survey • % Current • Past 30 DaysSmokingQuit Rate, % • No Mental Illness 23 43 • Major Depression 45 26 • Nonaffective Psychosis 45 0 • Gen. Anxiety Disorder 55 29 • Alcohol Abuse or Dependence 56 17 • Bipolar Disorder 61 26 • Drug Abuse or Dependence 68 22 (Source: Lasser et al., JAMA. 2000;284:2606-2610)

15. Smoking Rate and Number of Lifetime Psychiatric Diagnoses (Adapted from Lasser et al., 2000)

16. Tobacco Dependence and Mental Illness • Smokers with mental illnesses are aware of the health risks of smoking • However, nicotine may alleviate positive and negative psychiatric symptoms as well as side effects of psychiatric medications • Effective smoking cessation treatments are available for smokers with mental illness

17. U.S. Public Health Service Clinical Practice Guideline Michael C. Fiore, MD, MPH Panel Chair Published June, 2000 Evidence-based 50 meta-analyses of 6000 articles (1975-1999)

18. Putting the 5 A’s into PRACTICE: ASK – ADVISE – ASSESS – ASSIST- ARRANGE • Help develop a quit plan • Provide practical counseling • Provide intra-treatment social support • Encourage the smoker to seek social support • Recommend pharmacotherapy except in special circumstances • Provide supplementary materials

19. ASK – ADVISE – ASSESS – ASSIST- ARRANGE Pharmacotherapy • The Guideline recommends the use of FDA-approved pharmacotherapy, except when contraindicated • First-line medications: Bupropion SR, nicotine patch, nicotine gum, nicotine inhaler, nicotine nasal spray • Second-line medications: Clonidine, nortriptyline • (Although not available when the 2000 Guideline was developed, consider OTC nicotine lozenge, varenicline)

20. Who Should Receive Pharmacotherapy? • The Guideline recommends that ALL smokers trying to quit should be offered cessation medication except for special circumstances: • - medical contraindications • - smoke < 10 cigarettes/day • - pregnant/breastfeeding • - adolescent smokers

21. Guideline Recommendations for Smokers With Psychiatric Comorbidities • The antidepressants bupropion SR and nortriptyline should be considered for smokers with current or past history of depression • Stopping smoking may affect the pharmacokinetics of certain psychiatric medications: need to monitor • No specific recommendations in the Guideline for treating smokers with anxiety disorders

22. General Recommendations for Depressed Smokers • Smoking cessation treatment can be initiated in depressed smokers who are motivated to quit and clinically stable • Consider prescribing bupropion SR or nortriptyline (as appropriate given other possible psychotropic meds) • Consider nicotine replacement therapy (NRT) either as a first-line pharmacotherapy or to augment bupropion SR or nortriptyline

23. General Recommendations for Depressed Smokers • Consider varenicline as another first-line pharmacotherapy but do not combine with NRTs • There are no clinical studies of varenicline in combination with bupropion SR or nortriptyline (no concern about drug interactions according to Michael Fiore, M.D.) • Consider referral to a mental health specialist especially if the smoker’s depression is not responding to antidepressant pharmacotherapy alone

24. General Recommendations for Smokers With an Anxiety Disorder • Smoking cessation treatment can be initiated in anxious smokers who are motivated to quit and clinically stable • Neither bupropion SR nor nortriptyline are recommended for patients with anxiety disorders • SSRIs and benzodiazepines are commonly prescribed for anxious patients; neither of these has shown efficacy for smoking cessation

25. General Recommendations for Smokers With an Anxiety Disorder • Consider nicotine replacement medication as the first-line pharmacotherapy • Consider varenicline as another first-line pharmacotherapy but do not combine with NRTs • Consider referral to a mental health specialist especially if the smoker’s anxiety is not responding to pharmacotherapy alone

26. Real-World Use of Combination Pharmacotherapy Source: University of Medicine & Dentistry of New Jersey – Tobacco Dependence Clinic – Annual Report 2004

27. Case Studies

28. Contact Information Stevens S. Smith, Ph.D. Phone: 608-262-7563 sss@ctri.medicine.wisc.edu www.ctri.medicine.wisc.edu