Tobacco Cessation in Patients with Mental Illness

1. Tobacco Cessation in Patients with Mental Illness Eric L. Johnson, M.D. Physician Consultant North Dakota Tobacco Quitline Assistant Professor Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences

2. Objectives • Learn key points regarding tobacco use in the U.S. and in N.D. • Recognize tobacco cessation needs in persons with Mental Illness • Know resources and treatments available for persons with nicotine addiction in the setting of Mental Illness

3. Smoking Causes Death Smoking causes approximately • 90% of all lung cancerdeaths in men • 80% of all lung cancerdeaths in women • 90% of deaths from chronic obstructive lung disease (COPD) CDC

4. Smoking Causes Death Compared with nonsmokers smoking increases risk of— • Coronary heart disease by 2 to 4 times • Stroke by 2 to 4 times • Men developing lung cancer by 23 times • Women developing lung cancer by 13 times • Dying from chronic obstructive lung diseases (COPD) by 12 to 13 times CDC

6. Secondhand Smoke Deaths United States • Lung cancer – 3,000 deaths annually • Ischemic heart disease – 35,000 deaths annually North Dakota • 80-140 deaths annually

7. Tobacco Use in North Dakota • Adult smoking rates • 2001 23.2% • 2008 18.1% • Similar to national trends • 52% report cessation attempts annually Behavioral Risk Factor Surveillance System (BFRSS)

8. Tobacco Use in North Dakota • ~116,000 ND adults and ~8,000* HS students smoke cigarettes • ~20,000 ND adults and ~3,800^ HS students use spit tobacco (BRFSS 2008) (YRBS 2005,2007)

9. Tobacco Use in North Dakota • Native American population: 49.3% adults use tobacco (highest smoking rate of any ethnic group in U.S.) • Smoking in pregnancy higher in North Dakota than national average: 18% vs. 12% • WIC Clinic population survey: 45% smoked prior to pregnancy vs. 16% non-WIC

10. Tobacco’s Health Cost inNorth Dakota • Smoking-attributable direct medical expenditures: $250,000,000 • Smoking-attributable productivity costs: $192,000,000 • Medicaid expenditures for smoking-related illnesses and diseases: $47,000,000 Annual Costs! CDC. Smoking-Attributable Mortality, Morbidity and Economic Costs (SAMMEC) report, 2008. CDC Data Highlights, 2006.

11. Tobacco Use in North Dakota • Heart Disease and Cancer are the leading causes of death in North Dakota • Tobacco use is the leading preventable cause of death

12. Tobacco Use and Mental Illness

13. Tobacco Use and Mental Illness • Tobacco use in patients with a psychiatric diagnosis ~41% • Tobacco use patients without a psychiatric diagnosis ~20% Lasser, et al JAMA 2000

14. Tobacco Use and Mental Illness • Lifetime quit rates for ever smokers with a psychiatric diagnosis 16%-26% • Lifetime quit rates for ever smokers without psychiatric diagnosis ~42% • Persons with mental illness consume 30-50% of all tobacco sold in the U.S. Lasser, et al JAMA 2000 Fagerstrom and Aubin Curr Med Res Op 2009

15. Tobacco Use in Mental Illness Prevalence of cigarette smoking in clinical samples of individuals with PD and SUD. Data were compiled from clinical studies of smoking prevalence in major PD and SUD.4 Abbreviations: SZ, schizophrenia; BPD, bipolar disorder; MDD, major depressive disorder; PD, panic disorder; OCD, obsessive-compulsive disorder; PTSD, post-traumatic stress disorder. Am J Addict 2005

16. Neurotransmitter Systems of Relevance to the Co-Morbidity of Cigarette Smoking in PD and SUD Abbreviations: VTA, ventral tegemental area; NAc, nucleus accumbens; SN, substantia nigra; PFC, prefrontal cortex; ACC, anterior cingulated cortex; LC, locus ceruleus; RN, raphe nucleus; OFC, orbitofrontal cortex; NBM, nucleus basalis of Meynert; PPN, pedunculopontine nucleus; HIPP, hippocampus; PAG, periaquaductal gray; THAL, thalamus; CEREB, cerebellum. Am J Addict.2005

17. The Reward Pathway

19. Effect of Nicotine on Dopamine Levels NICOTINE 250 200 Accumbens Caudate % of Basal Release 150 100 0 1 2 3 hr 0 Time After Nicotine Source: Di Chiara and Imperato

20. Factors Influencing Smokingin Mental Illness • Genetic factors influencing both • Self-medication • Environmental factors (i.e., psychosocial stress) • Positive effects of nicotine: weight, mood, vigilance Kalman, et al Am J Addict 2005 Benowitz Ann Rev Pharm Tox 1999

21. Factors Influencing Smokingin Mental Illness • Nicotine may improve symptoms of schizophrenia • Nicotine may improve symptoms of depression • Withdrawal from nicotine may exacerbate symptoms in mental illness Dalak, et al Am J Psych 1999 Malpass and Higgs Psychopharm 2007

22. Tobacco and Schizophrenia

23. Tobacco and Schizophrenia • Patients with schizophrenia who smoke 20% reduction in life expectancy • Smoking-related fatal disease more common • Smoking rate as high as 80%+ Brown, et al Br J Psych 2000 Hennekens, et al Am Heart J 2005 deLeon Am J Psych 1995

24. Tobacco and Schizophrenia • Patients with schizophrenia who smoke lower quality of life -lower socio-economic status -more general health problems -more hospitalizations -poorer treatment compliance Montoya et al Am J Addict 2005

25. Tobacco and Depression • Smoking prevalence 40-60% • More difficult to quit • Require more cessation attempts • Cessation associated with negative affective symptoms Anda et al JAMA 1990 Niaura, et al Psych Add Beh 2001 Thorsteinsson, et al Neuropsychpharm 2001 Tsoh, et al Am J Psych 2000

26. Tobacco and Bipolar Disorder • Smoking prevalence 40-70% • Risk for recurrence with cessation • Less data in this population Hughes, et al Am J Psych 1986 Cassidy, et al Compr Psych 2002 Corvin et al Brit J Psych 2001

27. Tobacco and Anxiety Disorders • Smoking Prevalence -Panic Disorder 20-50% -OCD 7-20% -PTSD 53-66% Baker-Morissette, et al J Psychopath Beh 2004 Johnson, et al JAMA 2000 OpdenVelde, et al Alcohol Alcoholism 2002 Acierno, et al Beh Mod 1996

28. Issues in Smoking Cessation • Triggers • Mood changes • Withdrawal symptoms (most smokers underestimate) • Weight gain • Lack of support • Exposure to other smokers

29. Smoking Cessation Interventions in Mental Illness • Brief Office Counseling • Smoking Cessation Class (i.e., Public Health) • Third Party Payer programs • Quitlines • Online programs (i.e., Quitnet) • Pharmacologic

30. Pharmacotherapy

31. Pharmacotherapy • Nicotine replacement therapy (NRT) • Bupropion (Zyban, Wellbutrin) • Varenicline (Chantix) • First-line therapies USPHS Guidelines 2008

33. Nicotine replacement therapy: dosing Example: • Smokes 10 cigarettes a day- 10 mg of nicotine needs to be replaced • Smokes 20 cigarettes a day – 20 mg of nicotine • Smokes 40 cigarettes a day- 40 mg of nicotine

34. Bupropion • Inhibits reuptake of dopamine & norepinephrine • Exact mechanism of action in smoking cessation is not clear • Initially developed as an antidepressant • Promotes smoking cessation even in the absence of depression

35. Bupropion: precautions • Side effects: • Insomnia (35%) • Dry mouth (13%) • Seizures (1/1000) • Contraindications: • Seizure disorder • Eating disorder • MAO inhibitors • Severe hepatic cirrhosis • Alcohol use

36. Varenicline • A partial nicotine receptor antagonist • Binds to the nicotine receptors in the brain • “Feeds the need” for nicotine at the CNS level • Essentially a form of NRT

38. Varenicline • Most common side effects (0.5mg bid and 1 mg bid dosing) - nausea (16-30%) - insomnia (18-19%) - abnormal dreams (9-13%) • Weight-neutral • Possible negative psychiatric effects need to be considered

39. Nicotine Withdrawal • Symptoms -anger/irritability -depression/anxiety -insomnia -increased dream activity • Peak in 1st week, last 2-4 weeks • ~50% experience significant withdrawal symptoms • Severe withdrawal may aggravate/activate psychiatric symptoms Hughes Nic Tob Res 2007 Madden Addiction 1997 Stages J Clin Psych 1996

40. Management of Emergent Psychiatric Symptoms in Tobacco Cessation • Monitor for symptoms • NRT +/- buproprion if appropriate (depression) • Adjustment of other psych medications • Cognitive behavioral therapy (CBT) • Motivational Interviewing

41. Considerations/Complications of Smoking Cessation Therapy In Mental Illness • Tobacco can lower serum levels of some psychiatric drugs • Induction of CYPIA2 • Therefore, cessation may alter serum levels of some psychiatric drugs Fagerstrom and Aubin Curr Med Res Op 2009

42. Behavioral Interventions

43. Smoking Cessation Interventions 5A’s • 5 A’s • ASK about tobacco use (Tobacco as a vital sign) • ADVISE to quit • ASSESS willingness to make a quit attempt • ASSIST • those who are ready, with appropriate treatment • those who are not ready, with motivational counseling • ARRANGE for follow-up USPHS 2008

44. In Office Counseling • Brief • No additional cost • Slightly increases quit rates in non-pregnant adults

45. Classes • Maybe difficult to access in rural areas (variable) • Availability • Public Health, American Lung Association, Employers • Sometimes cost • Effective

46. Quitlines • Free • Widely available • Effective • ND Quitline ~30% 13 month quitrate in general population • ND Quitline Free NRT for qualifying • MN Quitplan

47. Online Services • Third party payers • ND Quitnet: Premium content to ND residents, launched Feb 2010 • ND Quitnet Free NRT

48. 1-800-784-8669 nd.quitnet.com Free to all North Dakota Residents Free NRT for qualifying

49. North Dakota Tobacco Quitline/Quitnet

50. Quitlines • Other surrounding states have quitlines • 1-800-QUITNOW is universal in U.S. • Third Party Payers, Health Care Systems