Tobacco use among individuals with schizophrenia: what role has the tobacco industry played?

The Association Between Chronic Tobacco Smoking and Brain Alterations in Schizophrenia: A Systematic Review of Magnetic Resonance Imaging Studies

BACKGROUND AND HYPOTHESIS

The high co-occurrence of tobacco smoking in patients with schizophrenia spectrum disorders (SSD) poses a serious health concern, linked to increased mortality and worse clinical outcomes. The mechanisms underlying this co-occurrence are not fully understood.

STUDY DESIGN

Addressing the need for a comprehensive overview of the impact of tobacco use on SSD neurobiology, we conducted a systematic review of neuroimaging studies (including structural, functional, and neurochemical magnetic resonance imaging studies) that investigate the association between chronic tobacco smoking and brain alterations in patients with SSD.

STUDY RESULTS

Eight structural and fourteen functional studies were included. Structural studies show widespread independent and additive reductions in gray matter in relation to smoking and SSD. The majority of functional studies suggest that smoking might be associated with improvements in connectivity deficits linked to SSD. However, the limited number of and high amount of cross-sectional studies, and high between-studies sample overlap prevent a conclusive determination of the nature and extent of the impact of smoking on brain functioning in patients with SSD. Overall, functional results imply a distinct neurobiological mechanism for tobacco addiction in patients with SSD, possibly attributed to differences at the nicotinic acetylcholine receptor level.

CONCLUSIONS

Our findings highlight the need for more longitudinal and exposure-dependent studies to differentiate between inherent neurobiological differences and the (long-term) effects of smoking in SSD, and to unravel the complex interaction between smoking and schizophrenia at various disease stages. This could inform more effective strategies addressing smoking susceptibility in SSD, potentially improving clinical outcomes.

A reduction in cigarette smoking improves health-related quality of life and does not worsen psychiatric symptoms in individuals with serious mental illness

INTRODUCTION

Individuals with serious mental illness (SMI) smoke cigarettes at a much higher rate than the general population, increasing their risk for medical illnesses and mortality. However, individuals with SMI do not get enough support to quit smoking, partially because of concerns from medical providers that reducing smoking may worsen their symptoms or quality of life.

METHODS

Veterans with SMI and nicotine dependence (n = 178) completed a 12-week smoking cessation trial (parent trial dates: 2010-2014) including assessments of smoking status, psychiatric symptoms (Brief Psychiatric Rating Scale), and quality of life (Lehman Quality of Life Interview-Short Version) at up to four time points: baseline, post-treatment, three-month follow-up, and 9-month follow-up. Bayesian multilevel modeling estimated the impact of changes in the self-reported number of cigarettes per day in the past seven days on psychiatric symptoms and quality of life.

RESULTS

Between subjects, each additional pack of cigarettes smoked per day was associated with a 0.83 point higher score (95%CI: 0.03 to 1.7) on a negative symptoms scale ranging from 0 to 35. Within subjects, each one-pack reduction in the number of cigarettes smoked per day was associated with an improvement of 0.32 (95%CI = 0.12 to 0.54) on the health-related quality of life scale, which ranges from 0 to 7 points. There were no other significant between- or within-subjects effects of smoking on psychiatric symptoms or quality of life.

CONCLUSIONS

Individuals with SMI and their providers should pursue smoking cessation without fear of worsening psychiatric symptoms or quality of life.

Pharmaceuticalisation as the tobacco industry's endgame

CONTEXT

Declining smoking prevalence and denormalisation of tobacco in developed countries reduced transnational tobacco company (TTC) profit during 1990s and 2000s. As these companies faced increasingly restrictive policies and lawsuits, they planned to shift their business to socially acceptable reduced-harm products. We describe the internal motivations and strategies to achieve this goal.

METHODS

We analysed previously secret tobacco industry documents available through the Truth Tobacco Documents Library. These documents were triangulated with TTCs' investor and other professional reports, websites and public statements.

FINDINGS

Mimicking pharmaceutical business models, tobacco companies sought to refurbish their image and ensure long-term profitability by creating and selling pharmaceutical-like products as smoking declined. These products included snus, heated tobacco products, e-cigarettes, nicotine gums and inhalers. Tobacco companies created separate divisions to develop and roll out these products, and the majority developed medical research programmes to steer these products through regulatory agencies, seeking certification as reduced-harm or pharmaceutical products. These products were regarded as key to the survival of the tobacco industry in an unfriendly political and social climate.

CONCLUSIONS

Pharmaceuticalisation was pursued to perpetuate the profitability of tobacco and nicotine for tobacco companies, not as a sincere search to mitigate the harms of smoking in society. Promotion of new pharmaceuticalised products has split the tobacco control community, with some public health professionals and institutions advocating for the use of 'clean' reduced-harm nicotine and tobacco products, essentially carrying out tobacco industry objectives.

Tobacco Use and Tobacco Dependence Management

Tobacco use is a major public health problem and the leading cause of preventable deaths in the United States and worldwide. Tobacco dependence determines tobacco use and is largely due to nicotine addiction. Such dependence is a disease resulting in a strong desire or compulsion to take tobacco, with difficulty in cessation of tobacco, along with persistent use despite overtly harmful consequences.

Outcomes Among People With Schizophrenia Participating in General-Population Smoking Cessation Treatment: An Observational Study

OBJECTIVE

People with schizophrenia are much more likely than others to smoke tobacco, raising risks of disease and premature mortality. These individuals are also less likely to quit successfully after treatment, but the few existing clinical and observational studies have been limited by small sample sizes, and have generally considered specialized treatment approaches. In this analysis, we examine outcomes, service use, and potential explanatory variables in a large sample of people with schizophrenia treated in a general-population cessation program.

METHOD

Our sample comprised 3,011 people with schizophrenia and 77,790 controls receiving free nicotine replacement therapy through 400 clinics and health centres. We analysed self-reported 7-day abstinence or reduction at 6-month follow-up, as well as the number of visits attended and self-reported difficulties in quitting. We adjusted for demographic, socioeconomic, and health variables, and used multiple imputation to address missing data.

RESULTS

Abstinence was achieved by 16.2% (95% confidence interval [CI], 14.5% to 17.8%) of people with schizophrenia and 26.4% (95% CI, 26.0% to 26.7%) of others (absolute difference = 10.2%; 95% CI, 8.5% to 11.9%; P < 0.001). After adjustment, this difference was reduced to 7.3% (95% CI, 5.4% to 9.3%; P < 0.001). Reduction in use was reported by 11.8% (95% CI, 10.3% to 13.3%) and 12.5% (95% CI, 12.2% to 12.8%), respectively; this difference was nonsignificant after adjustment. People with schizophrenia attended more clinic visits (incidence rate ratio [IRR] = 1.15, 95% CI = 1.12% to 1.18%, P < 0.001) and reported more difficulties related to "being around other smokers" (odds ratio [OR] = 1.28; 95% CI, 1.11% to 1.47%; P = 0.001).

CONCLUSION

There is abundant demand for tobacco cessation treatment in this population. Outcomes were substantially poorer for people with schizophrenia, and this difference was not explained by covariates. Cessation remained much better than for unaided quit attempts, however, and engagement was high, demonstrating that people with schizophrenia benefit from nonspecialized pharmacological treatment programs.

An Examination of the Effectiveness of Smoking Cessation Treatment Interventions for Individuals with Severe Mental Illness: A Pilot Randomized Controlled Trial

To evaluate the effectiveness of two different smoking cessation interventions for individuals with severe mental illness. Study participants (N = 61) randomly assigned to the SC-R group (n = 29) were offered 24 weeks of no cost Nicotine Replacement Treatment (NRT); participants assigned to the SC + group (n = 32) were offered 24 weeks of no cost NRT plus two initial individual counselling sessions of motivational interviewing and weekly psychosocial group support for 24 weeks. At 6 months the smoking cessation outcome was 7% for the SC-R group and 14% for the SC + group, but there was no statistically significant difference between the groups. Both groups showed a significant decrease in the number of cigarettes smoked per day and significant improvement in physical health functioning. Clients with severe mental illness, high prevalence of co-occurring substance use and experience of homelessness, are both interested and able to quit smoking and reduce cigarette use.

A selective literature review exploring the role of the nicotinic system in schizophrenia

Nicotine use is more prevalent in patients with psychiatric disorders, especially those diagnosed with psychotic illnesses. Previously, this higher prevalence has been partially attributed to the potential ameliorative effects of nicotine on symptom severity and cognitive impairment. Some healthcare professionals and patients perceive there is a beneficial effect of nicotine on mental health. Emerging data show that the harm associated with nicotine in the population of patients with mental health conditions outweighs any potential benefit. This paper will review the evidence surrounding the nicotinic system and schizophrenia, with a focus on any causality between nicotine and psychosis.

Impact of smoking bans and other smoking cessation interventions in prisons, mental health and substance use treatment settings: A systematic review of the evidence

ISSUES

We conducted a systematic review to examine whether smoking bans alone are effective in achieving smoking cessation in people released from prison, and patients discharged from mental health or substance use settings.

APPROACH

We searched health, criminology and social science databases. Detailed search strings were used to combine terms related to smoking bans and cessation interventions in prison, mental health and substance use treatment settings. We used backward and forward snowballing and manual hand searching to find additional studies. Studies were included if they: were published between 1 January 2000 and 25 February 2022; included a complete smoking ban; measured people released from prison and/or mental health and/or substance use patients smoking post-release/discharge from a smoke-free facility; and reported smoking cessation intervention and/or smoking ban outcomes. Methodological quality was assessed using the Effective Public Health Practice Project's Quality Assessment Tool for Quantitative Studies and reviewed by two authors.

KEY FINDINGS

People released from prison, mental health and substance use in-patients who experience a smoking ban while incarcerated or in in-patient settings often relapse to smoking shortly after release or discharge. We found that although smoking bans alone do not promote cessation, multi-component interventions in combination with smoking bans can significantly increase cessation rates post-release/discharge provided they support participants during this time.

CONCLUSIONS

There is limited evidence to suggest tobacco bans alone in prison, mental health and substance use treatment settings are effective in achieving long-term smoking cessation. This review suggests that combining smoking bans and cessation interventions including pre- and post-release/discharge support can be effective in achieving smoking cessation.

Disparities in smoking prevalence and associations with mental health and substance use disorders in underserved communities across the United States

BACKGROUND

Smoking contributes to the top 3 deadliest cancers, cancers of the lung, colon, and pancreas, which account for nearly 40% of all cancer-related deaths in the United States. Despite historicly low smoking rates, substantial disparities remain among people with mental health conditions and substance use disorders (SUDs).

METHODS

The study examined the prevalence of smoking among adults from underserved communities who are served at federally qualified health centers through an analysis of the 2014 Health Center Patient Survey. Furthermore, the study assessed associations of smoking with co-occurring mental health conditions and SUDs among adult smokers (n = 1735).

RESULTS

The prevalence of smoking among health center patients was 28.1%. Among current smokers, 59.1% had depression and 45.4% had generalized anxiety. Non-Hispanic Black smokers had more than 2 times the odds of reporting SUDs (adjusted odds ratio [aOR], 2.13; 95% confidence interval [CI], 1.06-4.30). Individuals at or below 100% of the federal poverty level had more than 2 times the odds of having mental health conditions (aOR, 2.55; 95% CI, 1.58-4.11), and those who were unemployed had more than 3 times the odds for SUDs (aOR, 3.21; 95% CI, 1.27-8.10).

CONCLUSIONS

The prevalence of smoking in underserved communities is nearly double the national prevalence. In addition, the study underscores important socioeconomic determinants of health in smoking cessation behavior and the marked disparities among individuals with mental health conditions and SUDs. Finally, the findings illuminate the unique need for tailored treatments supporting cancer prevention care to address challenges confronted by vulnerable populations.

An evaluation of junior doctors' experience in smoking cessation training in a rural mental health setting

INTRODUCTION

Smoking prevalence remains high amongst people with mental illness, however, they are less likely to be screened for tobacco dependence and offered treatment to quit. Smoking cessation and education training are insufficient in medical schools, despite a positive relationship between training and practice once qualified. However, the question as to whether there is adequate skill and expertise to address smoking in people with mental illness within Australian mental health settings is unclear. Furthermore, people living in rural and remote areas smoke at higher rates, quit at lower rates than those in urban areas, and experience limitations in their ability to access smoking cessation supports. The Smokers' Clinic is an initiative established in a rural Australian mental health service offering a smoking cessation service to patients and staff employed by the service.

AIM

This study aims to assess the change in the knowledge and confidence of resident medical officers in their understanding of nicotine dependence, smoking cessation strategies and prescribing nicotine replacement therapy in a community mental health setting. It was hypothesized that providing education and supervised clinical experience would improve knowledge, increasing confidence and motivation in managing smoking cessation in mental health patients. The research was undertaken using data collected through a questionnaire obtained from surveying resident medical officers administering the Smokers' Clinic following a 10-week rural community mental health rotation.

MATERIALS AND METHODS

Twenty resident medical officers completed the 10-week rotation, with 14 completing the questionnaire. Knowledge of tobacco smoking, nicotine dependence and smoking cessation interventions improved with the experience of the Smokers' Clinic during the clinical rotation. Resident medical officers were motivated to spend additional time engaged in self-directed learning and all reported continued use of acquired experience and information in their clinical work after the rotation.

CONCLUSION

This study indicates the utility of a novel approach in delivering education, training, building clinical expertise, and facilitating sustained clinical capacity amongst junior medical staff for smoking cessation in a rural community mental health setting. It offers an efficient approach for mental health services to deliver smoking cessation services to reduce the morbidity and mortality burden associated with tobacco smoking.

Delirium on clozapine: A tale of friend turned foe-A case report

Treatment resistant schizophrenia (TRS) is often encountered in clinical practice. Clozapine remains the drug of choice in the management of TRS. Several studies have shown that clozapine is the most effective antipsychotic medication to date for TRS. But it is also well known that it has multiple side effects. Some side effects are transient and relatively benign, while other adverse effects are menacing, serious and life-threatening. Delirium may occur with clozapine and is a therapeutic challenge as there is always a risk of precipitating delirium on clozapine rechallenge. Limited management strategies are available as alternatives for the management of psychiatric illness stabilized on clozapine. In this case report, we describe an older adult patient who developed delirium on clozapine. The aims of this case report are to discuss the mechanism by which clozapine leads to delirium, revisit various factors which could possibly lead to delirium, and discuss the different management strategies available for management of psychiatric illness for a patient previously stabilized on clozapine.

Systematic Review of Psychosocial Smoking Cessation Interventions for People with Serious Mental Illness

Tobacco smoking is a major driver of premature mortality in people with serious mental illness (SMI; e.g., schizophrenia, bipolar disorder). This systematic literature review described randomized control trials of psychosocial smoking cessation interventions for people with SMI, rated their methodological rigor, evaluated the inclusion of racial/ethnic and sexual/gender minorities, and examined smoking cessation outcomes. Methods: Eligible studies included peer-reviewed articles published between 2009 and 2020 that examined psychosocial smoking cessation interventions in people with SMI. We used the Preferred Reporting Items for Systematic Review and Meta-analysis guidelines to conduct our review and the Methodological Quality Rating Scale to evaluate methodological rigor. Results: Eighteen studies were included. Ten were categorized as high methodological rigor given their study characteristics (e.g., longer follow-up) and eight as lower methodological rigor based on their characteristics (e.g., not intent-to-treat). Racial/ethnic and sexual/gender minorities were under-represented in these studies. A range of psychosocial interventions were examined including motivational enhancements, smoking cessation education, cognitive behavioral strategies, and contingency management. Most studies also provided smoking cessation medications (e.g., NRT, bupropion), although provision was not always uniform across treatment conditions. Three studies found the intervention condition achieved significantly higher abstinence from smoking compared to the comparison group. Seven studies found the intervention condition achieved significantly higher reductions in smoking compared to the comparison group. Conclusions: Studies finding significant differences between the intervention and comparison groups shared common evidenced-based components, including providing smoking cessation medications (e.g., NRT, bupropion), motivational enhancement techniques, and cessation education and skills training, but differed in intensity (e.g., number and frequency of sessions), duration, and modality (e.g., group, individual, technology). Methodological limitations and a small number of studies finding significant between-group differences prevent the identification of the most effective psychosocial smoking cessation interventions. Clinical trial designs (e.g., SMART, factorial) that control for the provision of psychosocial medications and allow for the identification of optimal psychosocial treatments are needed. Future studies should also ensure greater inclusion of racial/ethnic and sexual/gender minorities and should be culturally/linguistically adapted to improve treatment engagement and study outcomes.

Prevalence and determinants of tobacco use amongst South African adults with mental illness in the Eastern Cape

Background

Given the physical and mental health consequences of tobacco use amongst individuals with mental illness, it was imperative to assess the burden of tobacco use in this population.

Aim

This study examined the patterns and factors associated with tobacco use in individuals attending the outpatient unit.

Setting

Cecilia Makiwane Hospital Mental Health Department in Eastern Cape province, South Africa.

Methods

Lifetime (ever use) use and current use of any tobacco products were examined in a cross-sectional study of 390 individuals between March and June 2020. A logistic regression was fitted to determine the correlates of lifetime and current use of any tobacco products.

Results

The rates of ever use and current use of tobacco products were 59.4% and 44.6%, respectively. Of the participants interviewed, lifetime tobacco use was more prevalent amongst individuals with schizophrenia (67.9%) and cannabis-induced disorders (97.3%) and lower in those with major depressive disorders (36.1%) and bipolar and related disorders (43.5%). Men were six times more likely to have ever used or currently use tobacco products in comparison to women. Also, those who had a salaried job or owned a business were over three times more likely to have ever used or currently use tobacco products compared with those receiving government social grants.

Conclusions

The prevalence of tobacco use in this study was significantly higher than the general population in the Eastern Cape. Therefore, smoking prevention and cessation interventions targeted at the general population should target this often neglected sub-population in the region.

Emotional symptoms and sensation seeking: Implications for tobacco interventions for youth and young adults

INTRODUCTION

Although emotional symptoms and sensation seeking are recognized as important risk factors for tobacco use among youth and young adults, to date, their joint influence on tobacco use has not been examined.

METHODS

Data used in this study are from the Texas Adolescent Tobacco and Marketing Surveillance study, a population-based cohort. At baseline, in 2014, participants were in the 10th grade. Mixed-effects logistic regression models examined associations between emotional symptoms and sensation seeking in 2014 and odds of past 30-day cigarette and e-cigarette use in 2018. Interactions between emotional symptoms and sensation seeking were examined to assess whether one modifies the effect of the other on cigarette and e-cigarette use.

RESULTS

After adjusting for age, sex, race/ethnicity, school type, and ever use of cigarettes or e-cigarettes at baseline, adolescents with high emotional symptoms (AOR_cig=1.97; 95% CI:1.07–3.60, and AOR_e-cig=1.68; 95% CI: 1.06–2.66) and with high sensation seeking tendencies (AOR_cig=2.05; 95% CI: 1.03–4.10, and AOR_e-cig=1.68; 95% CI: 1.02–2.76) had significantly higher odds of past 30-day cigarette and e-cigarette use four years later compared to adolescents with low emotional symptoms and low sensation seeking tendencies. The interaction was significant (p=0.01) for e-cigarette use only; among low sensation seekers, adolescents who reported high levels of emotional symptoms were at increased risk for past 30-day use (AOR_e-cig=3.43; 95% CI: 1.38–8.51), and among adolescents with low emotional symptoms, high sensation seekers were at increased for risk for past 30-day use (AOR_e-cig=3.50; 95% CI: 1.54–7.91).

CONCLUSIONS

It is important for tobacco use prevention programs to consider both behavioral risk factors – sensation seeking and emotional symptoms – in an integrative way, to target high risk subgroups and thereby increase the efficacy of existing effective intervention strategies in order to curb tobacco use among youth and young adults.

Cigarette Smoking and Schizophrenia: Etiology, Clinical, Pharmacological, and Treatment Implications

Recent data suggests that the prevalence of smoking in schizophrenia remains high. While reports suggest that smoking increases the risk of developing schizophrenia, the potential causative role of smoking in this relationship needs further investigation. Smokers with schizophrenia are more likely to have more intense positive symptoms and lower cognitive function, but diminished intensity of extrapyramidal side effects than nonsmoking patients with schizophrenia. They were also more likely to exhibit aggressive behaviour compared to nonsmokers, which could suggest higher levels of baseline aggression. The significant cost associated with regular tobacco expenditure can detract from investment in key domains. Large-scale trials have shown that pharmacotherapy for smoking cessation is effective and does not worsen the risk of developing neuropsychiatric symptoms compared to placebo. Electronic cigarette use among schizophrenia patients is high, and there is emerging evidence supportive of its efficacy. Future improvements include large-scale trials assessing the utility, efficacy, and safety of electronic cigarettes in schizophrenia patients.

Use of and perceptions about electronic nicotine delivery systems (ENDS) among people with mental health conditions or serious psychological distress, 2018

BACKGROUND

People with mental health conditions (MHC) experience health disparities related to combustible tobacco use, and recent studies suggest disproportionately high use of electronic nicotine delivery systems (ENDS, e.g., e-cigarettes) among adults with MHC. Continued surveillance of ENDS use by MHC status is needed, as well as in-depth examinations of why adults with versus without MHC are using ENDS.

METHODS

Using 2018 U.S. nationally representative data (N = 5878), this study examined associations between MHC and serious psychological distress (SPD) with ENDS use. Among current ENDS users (n = 544), associations between MHC and SPD with perceived benefits and reasons for using ENDS were also investigated.

RESULTS

Both MHC and SPD were associated with higher likelihood of having ever used ENDS, currently using ENDS, and currently using ENDS daily. There was an interaction between SPD and smoking status in predicting current ENDS use such that the association between SPD and higher current ENDS use was stronger among never smokers. Compared to those without MHC, participants with MHC indicated that using ENDS helped them feel more relaxed and that stress management was a more important reason for ENDS use.

CONCLUSIONS

U.S. adults with MHC (and particularly never smokers with SPD) report disproportionately high use of ENDS. Individuals with MHC may be particularly likely to use ENDS for relaxation and stress management.

Tobacco smoking in young people seeking treatment for mental ill-health: what are their attitudes, knowledge and behaviours towards quitting?

INTRODUCTION

Tobacco smoking is a leading cause of preventable death and disease worldwide. Adults with mental ill-health smoke tobacco at substantially higher rates than other adults, with public health approaches effective in the population overall having less impact on those with mental ill-health. However, less is known about the tobacco smoking behaviours, attitudes and knowledge of young people with mental ill-health, despite this being the peak period of onset for both mental illness and cigarette smoking.

METHODS

Young people attending a youth mental health centre (providing both primary and specialist care) in Melbourne, Australia were approached by youth peer researchers and asked to complete a survey about smoking behaviours, attitudes and knowledge. We examined smoking and associated attitudes in the sample overall, and as a function of the services accessed.

RESULTS

In total, 114 young people completed the survey, with 56.3% reporting lifetime cigarette smoking, 42.0% smoking in the last 12 months and 28.6% in the past week. Of current regular smokers, 75.0% acknowledged they should quit in the future; however, only 23.5% planned to do so in the next month, with 44.4% confident that they could quit. Participants lacked knowledge about interactions between tobacco smoking, mental and physical health.

CONCLUSIONS

Youth presenting for mental ill-health had high rates of cigarette smoking relative to population rates. Presentation at youth mental health services may represent a critical window for early intervention to reduce the lifetime impacts of cigarette smoking in mental ill-health. Interventions to support smoking cessation in this group are urgently needed.

Current advances in research in treatment and recovery: Nicotine addiction

The health harms of combusted tobacco use are undeniable. With market and regulatory pressures to reduce the harms of nicotine delivery by combustion, the tobacco product landscape has diversified to include smokeless, heated, and electronic nicotine vaping products. Products of tobacco combustion are the main cause of smoking-induced disease, and nicotine addiction sustains tobacco use. An understanding of the biology and clinical features of nicotine addiction and the conditioning of behavior that occurs via stimuli paired with frequent nicotine dosing, as with a smoked cigarette, is important for informing pharmacologic and behavioral treatment targets. We review current advances in research on nicotine addiction treatment and recovery, with a focus on conventional combustible cigarette use. Our review covers evidence-based methods to treat smoking in adults and policy approaches to prevent nicotine product initiation in youth. In closing, we discuss emerging areas of evidence and consider new directions for advancing the field.

Reasons for smoking and barriers to cessation among adults with serious mental illness: A qualitative study

AIMS

Most research into reasons for smoking among adults with serious mental illness (SMI) has focused on reasons related to SMI symptoms. The current study reports reasons for smoking and barriers to cessation that are both related and unrelated to SMI symptoms among adults with SMI.

METHODS

Four focus groups were conducted among current smokers receiving outpatient care for a psychotic disorder in 2017 (N = 24). Participants were asked why they currently smoke and their barriers to quitting smoking.

RESULTS

Smoking as a coping mechanism and to self-medicate SMI symptoms were reasons for current smoking and barriers to cessation. Avoidance of other unhealthy behaviors, routine, and enjoyment emerged as reasons for smoking and barriers to cessation that were unrelated to mental illness.

CONCLUSION

Consideration of factors that are both related and unrelated to SMI symptoms in smoking cessation interventions and brief cessation counseling may improve cessation success in this population.

The relationship between nicotine and psychosis

Cigarette smoking is strongly associated with psychotic disorders such as schizophrenia. For several decades it was assumed that the relationship could be explained by reverse causation; that smoking was secondary to the illness itself, either through self-medication or a process of institutionalization, or was entirely explained by confounding by cannabis use or social factors. However, studies have exposed that such hypotheses cannot fully explain the association, and more recently a bidirectional relationship has been proposed wherein cigarette smoking may be causally related to risk of psychosis, possibly via a shared genetic liability to smoking and psychosis. We review the evidence for these candidate explanations, using findings from the latest epidemiological, neuroimaging, genetic and preclinical work.

Natural American Spirit Brand Preference among Smokers with Mental Illness

INTRODUCTION

Despite a steady decline in the US smoking prevalence over the past 50 years, Natural American Spirit cigarettes (NAS), marketed as ‘natural’ and ‘organic’, have seen a 400% rise in sales. In a sample of smokers with mental illness, based on previous research, we hypothesized that preference for NAS would be associated with younger age, higher education, and a stronger health-orientation.

METHODS

Adult smokers were interviewed during acute psychiatric hospitalization in California between 2009–2013, reporting their preferred top three brands of cigarettes, smoking behaviors, self-rated health, and dietary and physical activity behaviors. The sample (N=956; Mean age=38.7 years, SD=13.5; 48.7% women) identified as 14.5% Hispanic ethnicity, 49.6% White, 23.7% African American, and 23.8% other.

RESULTS

NAS was identified as a top preferred brand by 15.2% of the participants and was the fourth most popular brand for the sample overall. In a multivariate logistic regression, preference for NAS was significantly greater among participants who were younger (OR=0.97), had some college education or more (OR=2.64 to 4.31), ate a low-fat diet (OR=1.56) and reported better overall health (OR=1.26), with p<0.05. Identifying as Hispanic (OR=1.80) or White (OR=3.00) also predicted NAS preference, p<0.05. NAS preference did not differ by gender or psychiatric diagnosis.

CONCLUSIONS

Study findings indicate greater NAS brand appeal among smokers living with mental illness who are younger, more highly educated, and have a stronger orientation to health, perhaps because they perceive NAS to be a ‘healthier’ cigarette to smoke. Marketing language that obscures the harms of smoking ought to be prohibited.

Tobacco smoking and schizophrenia: re-examining the evidence

Tobacco smoking among people with mental illnesses can be explained by biological, psychological and social factors. The prevalence of smoking in people diagnosed with schizophrenia is higher than in people with other mental disorders and in the general population. This article explores three current hypotheses that explain this higher prevalence of smoking in schizophrenia. The first, the self-medication hypothesis, is increasingly countered by a growing body of evidence indicating that smokers experience more severe symptoms of schizophrenia. Numerous researchers have already identified smoking as a possible risk factor for the development of schizophrenia, which is the second hypothesis. The third hypothesis (shared genetic vulnerability) identifies certain genes that confer vulnerability for both schizophrenia and nicotine dependence. Understanding the reasons behind the higher prevalence of smoking among people with schizophrenia is vital in planning effective primary, secondary and tertiary smoking prevention for these individuals.

LEARNING OBJECTIVES

At the end of this article, readers will be able to: •

Menthol cigarette use in young adult smokers with severe mental illnesses

INTRODUCTION

Smokers with severe mental illness (SMI) are more likely to start smoking and less likely to quit. Menthol may facilitate smoking progression, dependence, and maintenance by reducing harshness and irritation from smoking and providing a unique sensory experience during use. High rates of menthol use have been reported in smokers with SMI, but information on young adults with SMI has not been reported.

METHODS

This study provides a secondary analysis to assess the impact of menthol use in a pilot trial of brief tobacco interventions. Participants were assessed at baseline and again at a 3-month follow-up with structured interviews and breath carbon monoxide to confirm self-reported 7-day abstinence at follow-up.

RESULTS

Participants included 81 young adult smokers with SMI, mean age of 24.2 years (SD = 3.6; range 18-30). Overall, 58% of the group reported that they recently used a menthol-flavored product. Menthol use was correlated with race (African American [18/21, 85.7%] vs. White [24/53, 45.3%] or other race [5/7, 71.4%]; χ2 = 10.7, p = .005) and more lifetime psychiatric hospitalizations (t = 2.39, p = .02), but not with cigarettes per day, nicotine dependence, quit attempts over the follow-up period, nor with achieving biologically confirmed abstinence at the follow-up assessment.

CONCLUSIONS

The high prevalence of menthol-flavored cigarette use in this study group is consistent with previous reports of high rates of menthol use among young adults, Blacks, and middle-aged SMI smokers. This study supports existing evidence that policies to restrict menthol flavoring in combustible tobacco products could reduce smoking in young adults with SMI.

IMPLICATIONS

High rates of menthol use have been reported in middle-aged smokers with SMI, but information on young adults with SMI has not been reported. In this study, more than half (58%) of 81 young adult smokers with SMI used a menthol-flavored product. Menthol use was associated with race and with history of psychiatric hospitalizations. The research supports existing evidence that policies to restrict menthol flavoring in combustible tobacco products could reduce smoking in young adults with SMI.

Smokefree mental health inpatient settings – a matter of debate?

Abstract. Background: The prevalence of tobacco smoking among people with severe mental illness (SMI) substantially exceeds smoking rates in the general population and has been identified as the largest contributor to health inequalities in this group. Historically deeply embedded in the culture of mental health treatment environments, smoking until very recently was the norm in inpatient settings and still prevails in many settings internationally. In England however, mental health Trusts are currently implementing recent national guidance, according to which mental health settings will become entirely smokefree, with no exemptions, providing comprehensive evidence-based support to patients for smoking cessation and smoking abstinence during the inpatient stay. Aim: The aim of this article is to summarise the rationale for and the debate surrounding smokefree mental health inpatient settings, and to review and discuss the evidence on challenges, opportunities and impact of smokefree policy implementation in these settings, with a focus on the English debate and experience to date.

The Role of Mental Health and Substance Use in Homeless Adults' Tobacco Use and Cessation Attempts

Objective: Although tobacco use is prevalent among adults experiencing homelessness, research deficits exist regarding the mental health, substance use, and demographic correlates of tobacco use behaviors in this population. This study examined whether correlates of tobacco use among housed adults identified by the Center for Disease Control (CDC) were significant correlates of tobacco use and cessation attempts among a sample of homeless adults. Methods: Participants (N = 421) were adults experiencing homelessness entering permanent supportive housing programs in Los Angeles. Multivariate logistic regression determined associations of lifetime mental health diagnoses, recent substance use, demographic characteristics, and lifetime literal homelessness with daily tobacco use and cessation attempts. Results: Lifetime diagnoses of schizophrenia, posttraumatic stress disorder, depression, bipolar disorder, and illicit substance use were associated with increased odds of daily tobacco use. A lifetime diagnosis of depression was associated with an increased likelihood of a past 3-month tobacco cessation attempt, while illicit substance use was associated with a lower likelihood of a cessation attempt. Conclusions: Findings suggest that demographic and clinical characteristics associated with tobacco use differ among this sample of homeless adults and those identified by the CDC among housed adults. Mental health conditions and substance use appear to be the primary correlates of tobacco use among adults experiencing homelessness and may be critical in efforts aimed at improving cessation.

Electronic nicotine delivery system (ENDS) use in relation to mental health conditions, past-month serious psychological distress and cigarette smoking status, 2017

BACKGROUND AND AIMS

Adults with mental health conditions (MHC) exhibit disproportionately high smoking prevalence and experience profound tobacco-related disparities. US nationally representative surveys from 2012 to 2015 found relatively high usage of electronic nicotine delivery systems (ENDS; e.g. e-cigarettes) among adults with MHC. However, research has not examined these associations specifically among never smokers. Aims were to examine associations among MHC diagnosis, serious psychological distress (SPD) and ENDS use and to test whether associations varied by cigarette smoking status.

DESIGN

Cross-sectional US nationally representative survey.

SETTING

United States, 2017.

PARTICIPANTS

A total of 5762 adults (52.0% female; 64.8% non-Hispanic white, 11.4% non-Hispanic black, 15.9% Hispanic, 7.9% non-Hispanic other).

MEASUREMENTS

Outcomes were lifetime, current and current daily ENDS use. Predictors were lifetime MHC, past-month SPD and cigarette smoking status, and covariates were gender, age, race/ethnicity, education and annual household income.

FINDINGS

lifetime MHC and past-month SPD were each associated with higher likelihood of having ever used ENDS (P ≤ 0.001), currently using ENDS (P ≤ 0.001) and currently using ENDS daily (P < 0.05). There were interactions between MHC and smoking status in predicting ENDS use, such that MHC status predicted higher lifetime and current ENDS use specifically among never and current smokers. Never smokers with MHC had 2.62 higher odds [95% confidence interval, (CI) = 1.54, 4.45] of current ENDS use than those without MHC. Among never smokers, those with MHC indicated higher expectations that ENDS would improve relaxation and concentration (P < 0.05).

CONCLUSIONS

In 2017, US adults with versus without mental health conditions (MHC) were more likely to use electronic nicotine delivery systems (ENDS). In particular, both never and current smokers with MHC reported disproportionately high rates of current ENDS use.

'They're Going to Smoke Anyway': A Qualitative Study of Community Mental Health Staff and Consumer Perspectives on the Role of Social and Living Environments in Tobacco Use and Cessation

Background: Addressing the high prevalence of tobacco use experienced by people with severe mental illness (SMI) requires consideration of the influence of wider cultural, socioeconomic and environmental factors. This qualitative study aimed to examine the impact of social and living environments on tobacco use and cessation by people with SMI accessing community managed mental health services. The perspectives of both staff and consumers with SMI were explored. Methods: Semi-structured focus groups were undertaken with a purposive sample of community mental health staff and consumers from three sites in three major cities in NSW, Australia. Two sites provided outreach support, and one site provided residential support. Data were collected (2017-2018) until saturation was reached. Focus groups were audio-recorded and transcribed, and thematic analysis was conducted. Results: Thirty-one staff and 17 consumers participated separately in six focus groups. Themes identified by staff included a degree of fatalism, conceptualising tobacco use as choice rather than addiction and tensions between cessation support and broader models of care. Staff viewed smoke-free home and mental health service policies as effective at promoting quitting but contradictory to recovery-oriented models of care. Consumers identified smoking as an integral part of life and social networks, as a way of maintaining control and lack of social support to quit as key themes. While many consumers reported smoking inside the home, others described enforcing smoke-free rules. Conclusion: Social and living environments played an integral role in tobacco use and cessation for both staff and consumers. The role of community managed mental health organisations in addressing tobacco use within social and living environments was not strongly supported by staff and sometimes seen as antithetical to recovery-oriented models of care. Potential ways to address this include education and training for prospective and current community mental health organisation staff highlighting the synergy between the recovery-oriented model and provision of preventive health support.

Increased Connectivity Between the Nucleus Accumbens and the Default Mode Network in Patients With Schizophrenia During Cigarette Cravings

Objective: Compared to the general population, tobacco smoking cessation rates are lower in populations with schizophrenia. Unfortunately, the potential neurophysiologic mechanisms underlying these low cessation rates in schizophrenia have been seldom studied using functional neuroimaging. Recently, it has been shown that tobacco cravings are increased in smokers with schizophrenia compared to smokers with no comorbid psychiatric disorder. Given the critical role of the brain reward system in the neurobiology of addiction, we sought to examine the functional connectivity of core regions of this system in smokers with schizophrenia during the viewing of appetitive smoking cues. Methods: Smokers with (n = 18) and without (n = 24) schizophrenia were scanned using functional magnetic resonance imaging while viewing appetitive cigarette images. Functional connectivity analyses were performed using the bilateral nucleus accumbens as the seed regions. Results: Smokers with schizophrenia and smokers with no psychiatric comorbidity did not differ in subjective cravings in response to appetitive smoking cues. However, in smokers with schizophrenia relative to control smokers, we found an increased connectivity between the nucleus accumbens and regions involved in the default mode network (e.g., middle temporal gyrus and precuneus), which are involved in self-referential processes. Moreover, a positive correlation was observed between the left nucleus accumbens and left middle temporal gyrus connectivity and cigarette cravings across both groups of smokers. Conclusions: These results highlight a key role of the nucleus accumbens in cigarette craving in schizophrenia and suggest that the subjective valuation of cigarette cues is increased in this population. Similar neurofunctional studies on cravings for other psychoactive substances in schizophrenia are warranted.

Prediction of smoking by multiplex bisulfite PCR with long amplicons considering allele-specific effects on DNA methylation

Background

Methylation of DNA is associated with a variety of biological processes. With whole-genome studies of DNA methylation, it became possible to determine a set of genomic sites where DNA methylation is associated with a specific phenotype. A method is needed that allows detailed follow-up studies of the sites, including taking into account genetic information. Bisulfite PCR is a natural choice for this kind of task, but multiplexing is one of the most important problems impeding its implementation. To address this task, we took advantage of a recently published method based on Pacbio sequencing of long bisulfite PCR products (single-molecule real-time bisulfite sequencing, SMRT-BS) and tested the validity of the improved methodology with a smoking phenotype.

Results

Herein, we describe the “panhandle” modification of the method, which permits a more robust PCR with multiple targets. We applied this technique to determine smoking by DNA methylation in 71 healthy people and 83 schizophrenia patients (n = 50 smokers and n = 104 non-smokers, Russians of the Moscow region). We used five targets known to be influenced by smoking (regions of genes AHRR, ALPPL2, IER3, GNG12, and GFI1). We discovered significant allele-specific methylation effects in the AHRR and IER3 regions and assessed how this information could be exploited to improve the prediction of smoking based on the collected DNA methylation data. We found no significant difference in the methylation profiles of selected targets in relation to schizophrenia suggesting that smoking affects methylation at the studied genomic sites in healthy people and schizophrenia patients in a similar way.

Conclusions

We determined that SMRT-BS with “panhandle” modification performs well in the described setting. Additional information regarding methylation and allele-specific effects could improve the predictive accuracy of DNA methylation-based models, which could be valuable for both basic research and clinical applications.

Electronic supplementary material

The online version of this article (10.1186/s13148-018-0565-1) contains supplementary material, which is available to authorized users.

Cannabis regulatory science: risk-benefit considerations for mental disorders

The evolving legal cannabis landscape in the US continues to present novel regulatory challenges that necessitate the development of a Cannabis Regulatory Science. Two specific issues of concern within Cannabis Regulatory Science are (1) the impact that cannabis use has on the incidence, prevalence, and severity of mental disorders, and (2) how cannabis laws and regulations modify this impact. This paper first provides several conceptual points that are useful for evaluating the relationship between cannabis use and mental disorders. Second, it selectively reviews and comments on data relevant to the relationship between cannabis use and depression, several forms of anxiety, post-traumatic stress disorder, schizophrenia, and bipolar disorder. Next, regulatory and public health parallels between the nascent cannabis industry and the pharmaceutical, tobacco, and alcohol industries are discussed. The focus is on specific types of industry practices that may harm those with or at risk for mental disorders. Recommendations are then offered for legal cannabis regulations that could mitigate this harm. Last, future research goals are discussed for building the field of Cannabis Regulatory Science and addressing the potential negative impact of cannabis on those with mental disorders.

Motives and perceptions regarding electronic nicotine delivery systems (ENDS) use among adults with mental health conditions

BACKGROUND

Smoking rates are disproportionately high among adults with mental health conditions (MHC), and recent research suggests that among former smokers, those with MHC are more likely to use electronic nicotine delivery systems (ENDS). This study investigated reasons for ENDS use and related risk perceptions among individuals with versus without MHC.

METHODS

Among adult current ENDS users (n=550), associations between self-reported MHC diagnoses and motives for ENDS use and ENDS risk perceptions were examined, stratified by smoking status.

RESULTS

There were no significant associations between MHC status and ENDS motives or perceptions in the overall sample. However, current smokers with MHC indicated thinking more about how ENDS might improve their health, and former smokers with MHC reported thinking less about how ENDS might harm their health, compared to their counterparts without MHC. Former smokers with MHC rated several reasons for ENDS use (e.g., less harmful than regular cigarettes; to quit smoking; appealing flavors) as more important than did those without MHC.

CONCLUSIONS

Current and former smokers with MHC may be especially optimistic about health benefits of ENDS. However, they might also be prone to health risks of continued ENDS use or concurrent use with traditional cigarettes. It will be important for public health messaging to provide this population with accurate information about benefits and risks of ENDS.

Smoking by people with mental illness and benefits of smoke-free mental health services

Smoking is the largest single cause of preventable illness in the UK. Those with mental health problems smoke significantly more and are therefore at greater risk. The new Health Act (2006) will require mental health facilities in England to be completely smoke-free by 1st July 2008. This article reviews the current literature regarding how smoking affects both the physical and mental well-being of people with mental health problems. It also considers the effects of smoke-free policy in mental health settings.

The Convention on the Rights of Persons with Disabilities as a tobacco control tool in the mental health setting

BACKGROUND

Smoking rates remain high among people with mental health conditions, even though smoking contributes to negative mental health outcomes and is a leading cause of mortality. Many mental health facilities are not covered by smoke-free laws or do not encourage smoking cessation, and people with mental health conditions are often targeted in tobacco industry promotions.

OBJECTIVE

To analyse how the Convention on the Rights of Persons with Disabilities (CRPD), to which most countries are a Party, obliges State Parties to review policies and practices for tobacco control in the mental health setting.

METHOD

Analysis of CRPD Articles relevant to smoking and mental health.

RESULTS

The CRPD contains several provisions that oblige State Parties to address the issue of smoking and mental health, particularly in relation to quit services, smoke-free policies in mental health facilities, health education focused on correcting misperceptions about smoking and mental health, and protecting people with mental health conditions from tobacco industry targeting.

CONCLUSIONS

The CRPD is a potentially powerful tool to promote tobacco control in the mental health context.

Innovative approaches to support smoking cessation for individuals with mental illness and co-occurring substance use disorders

INTRODUCTION

Tobacco remains the leading preventable cause of death in the US, accounting for over 520,000 deaths annually. While the smoking prevalence has declined over the past 50 years, those with mental illness and addictive disorders continue to smoke at high levels and with significant tobacco-related health problems. Areas covered: This review highlights the epidemiology, contributing factors, and evidence-base for intervening upon tobacco use in those with mental illness and addictive disorders. Historically underprioritized, a growing body of literature supports treating tobacco within mental health and addiction treatment settings. Critically, treating tobacco use appears to support, and not harm, mental health recovery and sobriety. This review also summarizes novel, emerging approaches to mitigate the harms of cigarette smoking. Expert commentary: People with mental illness and addictive disorders have a high prevalence of tobacco use with serious health harms. Treating tobacco use is essential. Evidence-based strategies include individual treatments that are stage-matched to readiness to quit and combine cessation medications with behavioral therapies, supported by smoke-free policies in treatment settings and residential environments. Emerging approaches, with a focus on harm reduction, are electronic nicotine delivery systems and tobacco regulatory efforts to reduce the nicotine content in cigarettes, thereby reducing their addiction potential.

Smoking-related outcomes and associations with tobacco-free policy in addiction treatment, 2015-2016

OBJECTIVE

This study assessed changes in smoking-related outcomes in two cross-sectional samples of clients enrolled in addiction treatment and whether tobacco-free grounds policies were associated with smoking-related outcomes.

METHOD

Clients in 25 programs were surveyed in 2015 (N=1176) and 2016 (N=1055). The samples were compared on smoking prevalence, cigarettes per day (CPD), thinking of quitting, past year quit attempts, staff and clients smoking together, attitudes towards quitting, and tobacco-related services. Second, programs with (n=6) and without (n=17) tobacco-free grounds at both time points were compared on smoking-related outcomes. Last, we examined changes in these measures for two programs that adopted tobacco-free grounds between 2015 and 2016.

RESULTS

There was one difference across years, such that the mean score for the tobacco Program Service scale increased from 2.37 to 2.48 (p=0.043, effect size=0.02). In programs with tobacco-free grounds policies, compared to those without, both CPD and the rate of staff and clients smoking together were significantly lower. In the two programs where tobacco-free grounds were implemented during study years, client smoking prevalence decreased (92.5% v. 67.6%, p=0.005), the rate of staff and clients smoking together decreased (35.6% v. 4.2%, p=0.031), mean CPD decreased (10.62v. 8.24, p<0.001) and mean tobacco services received by clients increased (2.08v. 3.05, p<0.001).

CONCLUSION

Addiction treatment programs, and agencies responsible for licensing, regulating and funding these programs, should implement tobacco-free grounds policies.

Assessing dietary and lifestyle risk factors and their associations with disease comorbidities among patients with schizophrenia: A case-control study from Bahrain

OBJECTIVE

Acquired dietary habits and lifestyle behaviors of patients with schizophrenia may affect their life expectancy, disease complications and prognosis. The objectives of the current study were to assess the dietary habits and other lifestyle behaviors for Bahraini patients with schizophrenia, and to determine their associations with different medical comorbidities.

METHOD

A case-control study was conducted during the period of March to December 2016. A sample of 120 cases were recruited from the Psychiatric Hospital, Bahrain and age-sex-matched with 120 controls. Controls were recruited from primary health centres, and were free from serious mental illness. Dietary habits and lifestyle behaviors including smoking, alcohol intake and physical activity were assessed using a questionnaire. All medical records were reviewed retrospectively. Logistic regression analysis was used to identify dietary and lifestyle risk factors that are associated with one or more disease comorbidities.

RESULTS

Cases had higher prevalence of smoking and alcohol intake, excessive dietary intake, and decreased physical activity (all P<0.05) compared with controls. Cases appeared to be at higher risk for developing chronic medical conditions such as obesity, type 2 diabetes, hypertension, cardiovascular disease, and musculoskeletal disorders. Cases were three times more likely to have up to three or more medical comorbidities compared with controls. Excessive dietary intake and decreased physical activity were identified as the main risk factors.

CONCLUSION

Excessive caloric intake and decreased physical activity represent the main dietary and lifestyle risk factors associated with comorbidities among patients with schizophrenia in Bahrain.

Drug abuse staff and clients smoking together: A shared addiction

Smoking is endemic in drug abuse treatment populations, and smoking prevalence in this population appears unresponsive to existing tobacco control strategies. Clinical and policy guidelines encourage programs to address smoking among clients, and research has identified key barriers to doing so. This report explores the practice of staff and clients smoking together in drug treatment programs, and how this practice is associated with other tobacco-related measures. Clients (N=1113) were surveyed and program directors were interviewed in a national sample of 24 drug abuse treatment programs affiliated with the NIDA Clinical Trials Network. Clients were asked whether they observed staff and clients smoking together in their program and, using program as the unit of analysis, this measure was tested for its association with client-level and program-level tobacco-related outcomes. Higher rates of staff and client smoking together were associated with higher staff smoking prevalence (p=0.006), lower rates of client thoughts about quitting in the next 30days (p=0.027), more negative client attitudes toward quitting smoking (p=0.004), and with clients receiving fewer tobacco-related services (p=0.024). These findings illuminate an actionable, low cost policy intervention to address smoking in drug abuse treatment, which is to prohibit the practice of staff smoking together with clients. In the interest of the health of clients whom they serve, counselors, program directors, state regulatory agencies, and federal funding agencies should act to end this practice.

Impaired Coupling between the Dorsomedial Prefrontal Cortex and the Amygdala in Schizophrenia Smokers Viewing Anti-smoking Images

BACKGROUND

Cigarette smoking is highly prevalent in schizophrenia and is one of the main factors contributing to the significantly decreased life expectancy in this population. Schizophrenia smokers, compared to their counterparts with no comorbid psychiatric disorder, are largely unaware and indifferent to the long-term negative consequences of cigarette smoking. The objective of this study was to determine, for the first time, if these meta-cognitive deficits are associated with neuro-functional alterations in schizophrenia smokers.

METHODS

Twenty-four smokers with no psychiatric disorder and 21 smokers with schizophrenia (DSM-IV criteria) were scanned using functional magnetic resonance imaging and exposed to anti-smoking images. Granger causality analyses were used to examine the effective connectivity between brain regions found to be significantly activated.

RESULTS

Across groups, potent activations were observed in the left ventro-lateral prefrontal cortex, the left amygdala (AMG), and the dorsomedial prefrontal cortex (dmPFC). Using the dmPFC as a seed region, we found an abnormal negative connectivity from the dmPFC to the AMG in schizophrenia smokers during the viewing of anti-smoking stimuli. This abnormal connectivity was not present during the viewing of aversive stimuli unrelated to tobacco.

DISCUSSION

Given the well-established roles of the dmPFC in social cognition and of the AMG in emotional processing, our results suggest that the relative indifference of schizophrenia smokers regarding the negative consequences of tobacco smoking could be explained by a cognitive-affective dissonance.

Use of Electronic Nicotine Delivery Systems among Adults with Mental Health Conditions, 2015

Adults with mental health conditions (MHC) are especially likely to smoke and experience tobacco-related health disparities. Individuals with MHC may also use electronic nicotine delivery devices (ENDS) at disproportionately high rates. However, there is a relative dearth of knowledge regarding ENDS use among individuals with MHC. In a large representative sample of U.S. adults (n = 6051), associations between self-reported MHC diagnoses and ENDS use and susceptibility were examined, stratified by smoking status. Participants with MHC were approximately 1.5 times more likely to have used ENDS in their lifetime and almost twice as likely to currently use ENDS as those without MHC. MHC status was most strongly linked to higher ENDS use among former smokers, and former smokers with MHC were more likely to report using ENDS during past smoking quit attempts than those without MHC. Among participants who had not tried ENDS, former smokers with MHC were especially susceptible to future ENDS use. The potential advantage of ENDS for cessation purposes should be balanced with the risk of attracting former smokers with MHC to ENDS.

Smoking, Mental Illness, and Public Health

Tobacco use remains the leading preventable cause of death worldwide. In particular, people with mental illness are disproportionately affected with high smoking prevalence; they account for more than 200,000 of the 520,000 tobacco-attributable deaths in the United States annually and die on average 25 years prematurely. Our review aims to provide an update on smoking in the mentally ill. We review the determinants of tobacco use among smokers with mental illness, presented with regard to the public health HAVE framework of “the host” (e.g., tobacco user characteristics), the “agent” (e.g., nicotine product characteristics), the “vector” (e.g., tobacco industry), and the “environment” (e.g., smoking policies). Furthermore, we identify the significant health harms incurred and opportunities for prevention and intervention within a health care systems and larger health policy perspective. A comprehensive effort is warranted to achieve equity toward the 2025 Healthy People goal of reducing US adult tobacco use to 12%, with attention to all subgroups, including smokers with mental illness.

Diabetes and Cardiovascular Care Among People with Severe Mental Illness: A Literature Review

Close to 19 million US adults have severe mental illnesses (SMI), and they die, on average, 25 years earlier than the general population, most often from cardiovascular disease (CVD). Many of the antipsychotic medications used to treat SMI contribute to CVD risk by increasing risk for obesity, type 2 diabetes, dyslipidemia, and hypertension. Based on compelling evidence, the American Diabetes Association and the American Psychiatric Association developed guidelines for metabolic screening and monitoring during use of these medications.In this manuscript, we have reviewed the evidence on diabetes and other CVD risk screening, prevalence, and management among populations with SMI. We also review differences in screening among subpopulations with SMI (e.g., racial/ethnic minorities, women, and children). We found that despite national guidelines for screening for diabetes and other cardiovascular risk factors, up to 70 % of people taking antipsychotics remain unscreened and untreated. Based on estimates that 20 % of the 19 million US adults with SMI have diabetes and 70 % of them are not screened; it is likely that over 2 million Americans with SMI have unidentified diabetes. Given that undiagnosed diabetes costs over $4,000 per person, this failure to identify diabetes among people with SMI represents a missed opportunity to prevent morbidity and translates to over $8 billion in annual preventable costs to our healthcare system.Given the high burden of disease and significant evidence of suboptimal medical care received by people with SMI, we propose several clinical and policy recommendations to improve diabetes and other CVD risk screening and care for this highly vulnerable population. These recommendations include reducing antipsychotic medication dose or switching antipsychotic medications, enhancing smoking cessation efforts, sharing electronic health records between physical and mental health care systems, and promoting integration of care.

Increased ventro-medial prefrontal activations in schizophrenia smokers during cigarette cravings

BACKGROUND

Highly prevalent in schizophrenia, tobacco smoking substantially increases the risk of cardiac-related death. Compared to the general population, tobacco smoking cessation rates are lower in schizophrenia. Unfortunately, the reasons for these low cessation rates remain poorly understood. Recently, it has been shown that tobacco cravings are increased in schizophrenia smokers compared to smokers with no comorbid psychiatric disorder. In view of these results, we sought to examine - for the first time - the neurophysiologic responses elicited by cigarette cues in schizophrenia smokers. We hypothesized that cigarettes cues would elicit increased activations in brain regions involved in drug cravings in schizophrenia smokers relative to control smokers.

METHODS

Smokers with (n=18) and without (n=24) schizophrenia (DSM-IV criteria) were scanned using functional magnetic resonance imaging (fMRI) while viewing appetitive cigarette images.

RESULTS

Schizophrenia smokers and smokers with no psychiatric comorbidity did not differ in subjective cravings in response to appetitive smoking cues. However, in schizophrenia smokers relative to control smokers, we found that appetitive cigarette cues triggered increased activations of the bilateral ventro-medial prefrontal cortex, a core region of the brain reward system. Moreover, a negative correlation was observed between cigarette cravings and activations of the right ventro-medial prefrontal cortex in schizophrenia smokers.

DISCUSSION

The current results highlight a key role of the brain reward system in cigarette craving in schizophrenia, and suggest that the neurophysiologic mechanisms involved in the regulation of cue-induced cigarette craving are impaired in this population.

Cigarette and waterpipe smoking among adult patients with severe and persistent mental illness in Bahrain: a comparison with the National Non-communicable Diseases Risk Factors Survey

BACKGROUND

Smoking has been associated with several types of mental illness namely schizophrenia, depression, bipolar disorders with a prevalence of smoking twice that of the general population. The study objective was to ascertain whether waterpipe tobacco smoking (WTS), cigarette smoking and all types of tobacco smoking are more common among Bahraini patients with severe and persistent mental illness (SPMI) than the general population.

METHODS

A cross-sectional study was conducted on 222 adult SPMI both in- and out- patients who attended the Psychiatric Hospital in Bahrain. A 29-item questionnaire, which included sociodemographic variables, pattern and history of psychiatric illness and a comprehensive smoking history, was used. Comparative smoking data were obtained from the Bahraini National Non-communicable Diseases Risk Factors Survey.

RESULTS

The prevalence of smoking of tobacco among SPMI patients was 30.2 % compared to 19.9 % in the general population. The corresponding values for cigarette smoking were 25.2, 13.8 %, respectively and for WTS, 11.3, 8.4 %, respectively. SPMI patients were 1.7 (95 % CI 1.3, 2.4 %) times more likely to be smokers, 2.1 (95 % CI 1.5, 2.9 %) times, cigarette smokers and 1.4 (95 % CI 0.9, 1.9 %) times WTS than the general population. SPMI patients smoked at a younger age and consumed more cigarettes than the general population. The mean age started smoking was lower among men than women, similar for cigarettes, and higher for WTS.

CONCLUSIONS

The prevalence of smoking among patients with SPMI in Bahrain is twice that of the general population. The findings of the study have implications on the provision of healthcare to mentally ill patients in the country.

Responses to Tobacco Smoking-Related Health Messages in Young People With Recent-Onset Schizophrenia

Virtually no research has examined the responses of youth with recent-onset psychosis (ROP) to smoking-related health warnings. We examined predictors of response and tested hypotheses that participants with ROP would (a) assess warnings as less effective than a healthy comparison (HC) group, and (b) assess video warnings as more effective than pictures. ROP participants (n = 69) had <2 years of prior antipsychotic treatment; the HC group (n = 79) had no major mental illness. Participants viewed 10 pictorial warnings, 8 videos depicting similar messages, and were interviewed regarding tobacco use, health literacy, and smoking knowledge. We assessed response at baseline and at 4-week follow-up. ROP participants were more likely than HC to smoke tobacco (49.3% vs 10.1%) and had lower levels of health literacy and smoking-related knowledge. Cannabis was used by 46.4% of ROP participants. Effectiveness ratings were high for both picture and video warnings with no differences between media. ROP participants compared to HC and nonsmokers compared to smokers were more likely to perceive warnings as effective. Effectiveness was associated with negative affect and greater emotional arousal. We assessed 33 smokers at follow-up; 5 (15%) identified as nonsmokers, 15 (45%) made a quit attempt, and 16 (49%) reported that the warnings influenced their smoking. Results indicate that young people with psychotic disorders respond favorably to health warnings. Effective messages depict health consequences clearly, elicit negative emotions, and may impact smoking behavior. Future research is needed to understand the effects of mode of presentation and message comprehension on smoking behavior.