Achieving Smoking Cessation in Individuals with Schizophrenia: Special Considerations

Abstract

Premature mortality due to cardiovascular disease in those with schizophrenia is the largest lifespan disparity in the US and is growing; adults in the US with schizophrenia die on average 28 years earlier than those in the general population. Smoking prevalence among individuals with schizophrenia is estimated to be from 64–79%. Smokers with schizophrenia have historically been excluded from most large nicotine-dependence treatment studies. Converging evidence, however, indicates that a majority of smokers with schizophrenia want to quit smoking and that available pharmacotherapeutic smoking cessation aids are well tolerated by this population of smokers and effective when combined with behavioral treatment. The aim of this review is to present updated evidence for safety and efficacy of smoking cessation interventions for those with schizophrenia spectrum illness. We also highlight implications of the very low abstinence rates for smokers with schizophrenia who receive placebo plus behavioral treatment in randomized trials and review treatment approaches to address the high rate of rapid relapse observed upon pharmacologic treatment discontinuation in this population. Recommendations for monitoring for treatment-emergent nicotine withdrawal symptoms, side effects and effects of cessation on antipsychotic medication are also provided. Smokers with schizophrenia spectrum disorders should be encouraged to quit smoking and should receive varenicline, bupropion with or without nicotine replacement therapy, or nicotine replacement therapy, all in combination with behavioral treatment for at least 12 weeks. Maintenance pharmacotherapy may reduce relapse and improve sustained abstinence rates. Controlled trials in smokers with schizophrenia consistently show no greater rate of neuropsychiatric adverse events with pharmacotherapeutic cessation aids than with placebo.

Outcome of a psychosocial health promotion intervention aimed at improving physical health and reducing alcohol use in patients with schizophrenia and psychotic disorders (MINT)

“…Because smoking is common in patients with serious mental illness, it has also been an important target of behavioral interventions, with mixed results (Cather et al, 2017;McGinty et al, 2016). Smoking rates in patients with serious mental illness have declined much less than in those without such disorders (Cook et al, 2014).…”

Hidradenitis suppurativa and schizophrenia: a nationwide cohort study

“…The results of our study indicate that smoking is highly prevalent among schizophrenia patients, and even more prevalent among patients with HS and schizophrenia. The association between smoking and HS, as well as that between smoking and schizophrenia, is both well‐established . Moreover, it has been suggested that patients suffering from mental illnesses often smoke in an effort to relieve symptoms and associated distress, or to restore dopamine following a blockade caused by certain medications and diminish its side effects .…”

Natural cause mortality in persons with serious mental illness

“…Addressing cigarette smoking more vigorously would provide one strategy to reduce the excess mortality in this population. It is now established that many persons with serious mental illness can and do want to quit smoking , that there are smoking cessation treatments that are safe and effective , and that quitting also confers mental health benefits .…”