Perception of smoking risks and motivation to quit among nontreatment-seeking smokers with and without schizophrenia

Alcohol use history increases the likelihood of suicide behavior among male chronic patients with schizophrenia in a Chinese population

AIMS

This study was designed to detect the association between the history of alcohol drinking and suicidality in schizophrenia (SCZ) inpatients in a Chinese population.

METHODS

We recruited 616 male SCZ inpatients and collected demographic and clinical data. Five-factor model of the Positive and Negative Syndrome Scale (PANSS) was used to assess their psychopathological symptoms.

RESULTS

Our results showed that 31.33% of SCZ patients had a history of alcohol drinking. They had higher rates of lifetime suicide attempt and suicidal ideation than those without a history of alcohol drinking. Moreover, patients with a history of drinking were more likely to attempt suicide (14.51% vs. 7.09%; χ²  = 7.70, df = 1, p = 0.006), with an odds ratio (OR) of 2.22 and have suicidal ideation (29.02% vs. 17.49%; χ²  = 9.89, df = 1, p = 0.002), with an OR of 1.93. In addition, patients who used to drink alcohol were more likely to be smokers and had more severe positive and depressive symptoms (all p < 0.05).

CONCLUSIONS

Our study indicates that history of alcohol drinking may increase the prevalence of lifetime suicide attempt and suicidal ideation in male patients with chronic SCZ. Moreover, the history of alcohol drinking may be associated with some demographic data and clinical symptoms.

Comparison of Perceptions and Smoking Cessation Experiences Between Smokers With and Without Serious Mental Illness in a Large Health Maintenance Organization

OBJECTIVE

Smoking prevalence is threefold higher among people with serious mental illness (PWSMI) than in the general population, yet smoking cessation rates for PWSMI are lower. Numerous reasons have been posited as to why tobacco use is higher and abstinence rates are lower among PWSMI. This study explores smoking cessation perceptions and experiences among PWSMI and people without serious mental illness (SMI).

METHODS

Participants in this cross-sectional study were recruited from among members of a large health maintenance organization (HMO) in Israel who had registered for or commenced a smoking cessation program in 2015 through 2017. The sample comprised 208 PWSMI and a matched sample of people without SMI (N = 428). Telephone surveys were used to collect information about smoking status and smoking/cessation history, use of smoking cessation programs and aids (prescription medications, nicotine replacement therapy, electronic cigarettes), motivation and intention to quit, self-efficacy (to quit), smoking cessation outcome expectancies, physician support to quit, barriers and facilitators for those who had not quit, and reinforcements/challenges for those who had quit.

RESULTS

Of those without SMI, 27% quit smoking compared to 20% of PWSMI (p = .051). Irrespective of mental health status, the most significant predictor of abstinence was the use of smoking cessation prescription medications. Family physicians were significantly less likely to inquire about motivation to quit, refer to smoking cessation programs, or prescribe smoking cessation medications for PWSMI than for people without SMI. Beyond these factors, no differences were noted between respondents with and without SMI regarding motivation to quit, intention to quit, and abstinence self-efficacy. PWSMI who had not quit were more likely to be concerned about how quitting might affect their functioning and how they would pass the time without cigarettes.

CONCLUSIONS

PWSMI have similar levels of motivation and intention to quit smoking as those without SMI. However, they are disadvantaged by the reduced support received from their family physicians and lower cessation medication usage. Efforts to promote the implementation of smoking cessation treatment guidelines will help promote smoking abstinence among PWSMI.

The association between smoking behaviour, social cognition and social functioning in patients with a non-affective psychotic disorder: A prospective follow-up study

Introduction

In patients with psychotic disorders, both tobacco smoking and deficits in social cognition and social functioning are highly prevalent. However, little is known about their relationship in psychosis. The authors sought to evaluate the multi-cross-sectional and longitudinal associations between tobacco smoking, social cognition and social functioning in a large prospective study.

Methods

This study was performed within the Genetic Risk and Outcome of Psychosis (GROUP) Study, a cohort study conducted in patients with non-affective psychosis (N = 1074), their unaffected siblings (N = 1047) and healthy controls (N = 549). At baseline, three years and six years of follow-up, data on tobacco smoking (using the Composite International Diagnostic Review), social cognition (emotion processing and theory of mind) and social functioning were collected. To assess associations between tobacco smoking and social cognition or social functioning, multivariate linear mixed-effects models and multiple linear regression models were used. Bonferroni correction for multiple testing was applied.

Results

A significant positive association was found between smoking and emotion processing (as part of social cognition) in the patient group (estimate = 1.96, SE = 0.6, p = 0.003). However, smoking was significantly negatively associated with participating in pro-social activities compared with non-smoking (estimate = −2.55, SE = 0.9, p = 0.004). Change in smoking behaviour was not associated with social cognition or social functioning in the longitudinal analyses.

Conclusion

Findings indicate that smoking patients with a non-affective psychotic disorder slightly outperformed their non-smoking peers on a task on social cognition, but participated less in pro-social activities. Commencement or cessation of smoking was not related to social cognition or functioning.

Chronic obstructive pulmonary disease in severe mental illness: A timely diagnosis to advance the process of quitting smoking

Background

This study has two main objectives: to describe the prevalence of undetected chronic obstructive pulmonary disease (COPD) in a clinical sample of smokers with severe mental illness (SMI), and to assess the value of the Tobacco Intensive Motivational Estimated Risk tool, which informs smokers of their respiratory risk and uses brief text messages to reinforce intervention.

Method

A multicenter, randomized, open-label, and active-controlled clinical trial, with a 12-month follow-up. Outpatients with schizophrenia (SZ) and bipolar disorder were randomized either to the experimental group—studied by spirometry and informed of their calculated lung age and degree of obstruction (if any)—or to the active control group, who followed the 5 A’s intervention.

Results

The study sample consisted of 160 patients (71.9% SZ), 78.1% of whom completed the 12-month follow-up. Of the patients who completed the spirometry test, 23.9% showed evidence of COPD (77.8% in moderate or severe stages). TIMER was associated with a significant reduction in tobacco use at week 12 and in the long term, 21.9% of patients reduced consumption and 14.6% at least halved it. At week 48, six patients (7.3%) allocated to the experimental group achieved the seven-day smoking abstinence confirmed by CO (primary outcome in terms of efficacy), compared to three (3.8%) in the control group.

Conclusion

In this clinical pilot trial, one in four outpatients with an SMI who smoked had undiagnosed COPD. An intensive intervention tool favors the early detection of COPD and maintains its efficacy to quit smoking, compared with the standard 5 A’s intervention.

Determinants of Physical Health Self-Management Behaviours in Adults With Serious Mental Illness: A Systematic Review

Behavioural interventions can support the adoption of healthier lifestyles and improve physical health outcomes, but it is unclear what factors might drive success of such interventions in people with serious mental illness (SMI). We systematically identified and reviewed evidence of the association between determinants of physical health self-management behaviours in adults with SMI. Data about American Association of Diabetes Educator's Self-Care Behaviours (AADE-7) were mapped against the novel Mechanisms of Action (MoA) framework. Twenty-eight studies were included in the review, reporting evidence on 104 determinant-behaviour links. Beliefs about capabilities and beliefs about consequences were the most important determinants of behaviour, especially for being physically active and healthy eating. There was some evidence that emotion and environmental context and resources played a role in determining reducing risks, being active, and taking medications. We found very limited evidence associated with problem solving, and no study assessed links between MoAs and healthy coping. Although the review predominantly identified evidence about associations from cross-sectional studies that lacked validated and objective measures of self-management behaviours, these findings can facilitate the identification of behaviour change techniques with hypothesised links to determinants to support self-management in people with SMI. Systematic Review Registration: PROSPERO, registration CRD42018099553.

Approved and emerging smoking cessation treatments for people with schizophrenia spectrum disorders: A narrative review

This review focuses on smoking cessation treatments for people with schizophrenia spectrum disorders. It concludes with comments on the significance of the research and why it constitutes an original contribution. We searched PubMed (National Library of Medicine), and PsycINFO (Ovid) (2006-2020) for studies on schizophrenic disorder (schizophrenia or psychotic or psychosis or severe mental illness) and smoking cessation treatment (smoking cessation treatment or varenicline or tobacco cessation or reduction or bupropion or NRT or behavioral treatment or e-cigarette). Studies found evidence suggesting that pharmacotherapy combined with behavioural therapy for smoking cessation is effective amongst smokers with schizophrenia spectrum disorders, although more long-term research is required. This review summarised and critically reviewed also studies on vaping as a smoking cessation strategy for smokers with schizophrenia spectrum disorders and evidence suggests that they may effective as smoking cessation tool and may be less harmful alternatives to combustible cigarette smoking. Consequently, e-cigarettes could be considered as an applicable instrument for Tobacco Harm Reduction (THR) and smoking cessation. Overall, there are very few studies of e-cigarettes for smoking cessation in patients with schizophrenia and these studies are very small. They have promising results, but more research is needed.

Tobacco smoking, related harm and motivation to quit smoking in people with schizophrenia spectrum disorders

This narrative review focuses on the topic of tobacco smoking amongst people with schizophrenia spectrum disorders. We searched PubMed, PsycInfo and Scopus databases for schizophrenia spectrum disorders and smoking and included articles about the epidemiology of tobacco smoking in people with schizophrenia spectrum disorders, examining the relationship between smoking and mental health. This narrative review describes that a higher prevalence, frequency and impact of both high nicotine dependence and its harmful effects in patients with schizophrenia spectrum disorders compared with those in the general population. Despite several existent theories, the reasons for high smoking rates, the high dependence on nicotine and severity of nicotine withdrawal symptoms are not fully understood. The main aim of this paper is to inform mental health personnel and particularly clinical and health psychologists about the impact and role of tobacco smoking for smokers with schizophrenia spectrum disorders.

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.

Smoking cessation opportunities in severe mental illness (tobacco intensive motivational and estimate risk - TIMER-): study protocol for a randomized controlled trial

Background

There is an increased risk of premature death in people with severe mental illness (SMI). Respiratory disorders and cardiovascular disease are leading causes of increased mortality rates in these patients, and tobacco consumption remains the most preventable risk factor involved. Developing new tools to motivate patients towards cessation of smoking is a high priority. Information on the motivational value of giving the lung age and prevention opportunities is unknown in this high-risk population.

Methods/design

This article describes in detail a protocol developed to evaluate an intensive motivational tool, based on the individual risks of pulmonary damage and prevention opportunities. It is designed as a randomized, 12-month, follow-up, multicenter study. A minimum of 204 smokers will be included, aged 40 years and older, all of whom are patients diagnosed with either schizophrenia or bipolar disorder (BD). Chronic obstructive pulmonary disease (COPD) will be evaluated using spirometry, and the diagnosis will then be validated by a pneumologist and the lung age estimated. Based on this value, a motivational message about prevention will be issued for the intervention group, which will be reinforced by individualized text messages over a period of 3 months.

The efficacy of the method and the pulmonary damage variables will be evaluated: smoking cessation at the end of follow-up will be confirmed by cooximetry, and the COPD diagnosis and the severity of the staging for disease will be assessed.

Discussion

In the context of community care, screening and early detection of lung damage could potentially be used, together with mobile technology, in order to produce a prevention message, which may provide patients with SMI with a better chance of quitting smoking.

Trial registration

ClinicalTrials.gov, ID: NCT03583203. Registered on 11 July 2018.

Trial status: recruitment.

Stop Turning a Blind Eye: Tobacco Smoking Among Egyptian Patients With Schizophrenia

Background: Patients with schizophrenia have considerably higher rates of mortality than general population. Multiple factors may play a role in this. Despite being a major preventable cause of death, smoking is usually overlooked when dealing with patients with schizophrenia. Understanding the pattern of smoking, its severity, and the reasons to quit might be helpful in managing patients with schizophrenia and decreasing the mortality gap. Subjects and Methods: The study included smokers divided into two groups; the first included 346 patients with schizophrenia while the second group had 150 smokers with no mental illness. Both groups were assessed and compared regarding sociodemographic variables, pattern of smoking, severity of nicotine dependence, and motivation to quit smoking. Results: Earlier age of starting to smoke, higher number of cigarettes per day, and lower dependency scores were noted in patients with Schizophrenia. Positive correlation was found between positive symptoms and severity of dependence. Specific positive symptoms were correlated to number of cigarettes per day and time before first cigarette. Patients with Schizophrenia showed a significant difference in intrinsic reasons to quit (health concerns and self-control), which were also positively correlated to their positive symptoms score. Linear regression analysis for predictors of FTND score revealed that only age, sex, and schizophrenia were significant predictors of FTND score. Conclusion: Patients with schizophrenia smoke at earlier ages and smoke more cigarettes per day, yet, have less severe dependence than non-schizophrenic counterparts. Positive symptoms play a role in their smoking pattern and severity. Health concerns and self-control are their main motives to quit smoking.

A Systematic Review of Psychosocial Barriers and Facilitators to Smoking Cessation in People Living With Schizophrenia

Background: People living with schizophrenia are less likely to quit smoking compared with the general population and people living with other psychiatric disorders. Understanding the schizophrenia-specific psychosocial barriers and facilitators to smoking cessation is important for designing effective smoking cessation interventions. We aimed to systematically review research examining psychosocial barriers and facilitators to smoking cessation in people living with schizophrenia. Methods: We followed the PRISMA statement to conduct a systematic literature review examining psychosocial barriers and facilitators to smoking cessation in people living with schizophrenia. We searched EMBASE, Medline, PsycINFO, and CINAHL databases from inception to 14 June 2018 to identify relevant articles. We included peer-reviewed original research articles that examined psychosocial barriers and facilitators to smoking cessation, as well as factors associated with maintenance of smoking habits in people living with schizophrenia spectrum disorders. Qualitative, quantitative, or mixed-methods study designs were included. Three authors screened titles, abstracts, and full-texts using the eligibility criteria. We conducted a narrative synthesis of the data to account for the heterogeneity of study designs. We analyzed qualitative and quantitative studies separately. Results: We identified 685 studies from our systematic search and screened the full-text of 134 articles. The final set of 23 articles included 20 quantitative studies and 3 qualitative studies. The most commonly cited barrier to smoking cessation in people living with schizophrenia was cravings and addiction, followed by a perceived increased risk of negative affect associated with quitting smoking. People living with schizophrenia reported smoking to manage stress and to maintain social relationships. People living with schizophrenia were found to be less likely to receive cessation support from health professionals than smokers without schizophrenia. Health concerns were the most commonly mentioned facilitator to quit smoking. Conclusions: People living with schizophrenia experience a wide range of barriers to smoking cessation. The influence of these barriers on smoking cessation likelihood may be greater among people living with schizophrenia than people without psychiatric disorders. Health professionals play an important role in smoking cessation for people living with schizophrenia and should consider barriers and facilitators identified in this review to support quitting in this vulnerable population.

Nicotine dependence is associated with depression and childhood trauma in smokers with schizophrenia: results from the FACE-SZ dataset

In a perspective of personalized care for smoking cessation, a better clinical characterization of smokers with schizophrenia (SZ) is needed. The objective of this study was to determine the clinical characteristics of SZ smokers with severe nicotine (NIC) dependence. 240 stabilized community-dwelling SZ smokers (mean age = 31.9 years, 80.4% male gender) were consecutively included in the network of the FondaMental Expert Centers for Schizophrenia and assessed with validated scales. Severe NIC dependence was defined by a Fagerstrom questionnaire score ≥ 7. Depression was defined by a Calgary score ≥ 6. Childhood trauma was self-reported by the Childhood Trauma Questionnaire score (CTQ). Ongoing psychotropic treatment was recorded. Severe NIC dependence was identified in 83 subjects (34.6%), depression in 60 (26.3%). 44 (22.3%) subjects were treated by antidepressants. In a multivariate model, severe NIC dependence remained associated with depression (OR = 3.2, p = 0.006), male gender (OR = 4.5, p = 0.009) and more slightly with childhood trauma (OR = 1.03, p = 0.044), independently of socio-demographic characteristics, psychotic symptoms severity, psychotropic treatments and alcohol disorder. NIC dependence was independently and strongly associated with, respectively, depression and male gender in schizophrenia, and only slightly with history of childhood trauma. Based on these results, the care of both nicotine dependence and depression should be evaluated for an effective smoking cessation intervention in schizophrenia.

Achieving Smoking Cessation in Individuals with Schizophrenia: Special Considerations

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. The rate of smoking prevalence among individuals with schizophrenia is estimated to be from 64 to 79%. Smokers with schizophrenia have historically been excluded from most large nicotine-dependence treatment studies. However, converging evidence 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 are 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 (NRT), or NRT, 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.

Antipsychotic Treatment and Tobacco Craving in People With Schizophrenia

OBJECTIVE

Nicotine dependence is high in schizophrenia, and craving is known to impact relapse during quit attempts.

METHODS

We compared tobacco craving in smokers with schizophrenia treated with different antipsychotics.

RESULTS

Mean craving scores were lowest in participants receiving first-generation antipsychotics, although these differences were not statistically significant. Craving with clozapine was not lower than with other antipsychotics.

CONCLUSIONS

Further research is needed to determine whether differences in craving exist between antipsychotic classes.

Predictors of the Perception of Smoking Health Risks in Smokers With or Without Schizophrenia

OBJECTIVE

This study sought to examine the predictors of health risk perception in smokers with or without schizophrenia.

METHODS

The health risk subscale from the Smoking Consequences Questionnaire was dichotomized and used to measure health risk perception in smokers with (n = 67) and without schizophrenia (n = 100). A backward stepwise logistic regression was conducted using variables associated at the bivariate level to determine multivariate predictors.

RESULTS

Overall, 62.5% of smokers without schizophrenia and 40.3% of smokers with schizophrenia completely recognize the health risks of smoking (p ≤ .01). Multivariate predictors for smokers without schizophrenia included: sex (Exp (B) = .3; p < .05), Smoking Consequences Questionnaire state enhancement (Exp (B) = .69; p < .01), and craving relief (Exp (B) = 1.8; p < .01). Among smokers with schizophrenia, predictors were education (Exp (B) = .7; p < .05), nicotine dependence (Exp (B) = .5; p < .01), motivation to quit (Exp (B) = 1.8; p < .01), and Smoking Consequences Questionnaire craving relief (Exp (B) = 1.8; p < .01).

CONCLUSIONS

There was overlap and differences between predictors in smokers with and without schizophrenia. Commonly used techniques for education on the health consequences of cigarettes may work in smokers with schizophrenia, but intervention efforts specifically tailored to smokers with schizophrenia might be more efficacious.

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.

Adjunctive varenicline treatment for smoking reduction in patients with schizophrenia: A randomized double-blind placebo-controlled trial

OBJECTIVES

Smoking is more common among patients with schizophrenia than it is in the general population. Varenicline, a partial and full agonist at the α4β2 and α7 nicotine acetylcholine receptors, respectively, has been shown to be an effective anti-smoking treatment. This study examined the effects of varenicline treatment on smoking reduction in patients with schizophrenia.

METHODS

Sixty smokers with schizophrenia were recruited and randomized to receive either varenicline or placebo. Smoking behavior was assessed with the Minnesota Nicotine Withdrawal Scale (mNWS), Brief Questionnaire of Smoking Urge (QSU-brief), and Modified Cigarette Evaluation Questionnaire (mCEQ). Exhaled carbon monoxide was also measured to assess smoking dependency and status. Data were analyzed with the two-tailed Student's t-test, χ(2) test, and repeated measures ANOVA.

RESULTS

During the 8-week study, there was a significant time×group interaction, which showed that smoking decreased over time in the varenicline group. Expired CO levels also decreased in the varenicline group, showing a significant time effect, group effect, and time×group interaction. Total mCEQ scores decreased in the varenicline group, demonstrating a significant time×group interaction. Among the five domains of the mCEQ, the smoking satisfaction, psychological reward, and enjoyment of respiratory tract sensation domains showed significant time×group interactions in the varenicline group. The QSU-brief and mNWS demonstrated a significant time effect, but not significant time×group interactions. Adjunctive varenicline treatment with antipsychotics was generally well-tolerated and safe.

CONCLUSIONS

Varenicline showed significant efficacy in reducing smoking in people with schizophrenia.

The Quit Experience and Concerns of Smokers With Psychiatric Illness

INTRODUCTION

The purpose of this study is to better understand the quit experience and concerns of smokers with psychiatric illness (i.e., major depressive, anxiety, psychotic and bipolar disorders) in comparison with those without psychiatric illness.

METHODS

Smokers (N=732) with (n=430, 59%) and without psychiatric illness, recruited between June 2010 and March 2013 to participate in the FLEX (Flexible and Extended Dosing of Nicotine Replacement Therapy [NRT] and Varenicline in Comparison to Fixed-Dose NRT for Smoking Cessation) smoking-cessation trial, completed questionnaires assessing previously used cessation aids and reasons for relapse, and motivation and concerns about their upcoming quit attempt. These supplementary data analyses were conducted in May 2015.

RESULTS

The most commonly used cessation methods during previous attempts were nicotine replacement therapy (66.4%), cold turkey (59.7%), and bupropion (34.7%); no group differences were identified. Stress was the most common precipitator of relapse during previous attempts in all groups (43.6%), particularly among participants with depression and anxiety. Health was the most common motivation for the upcoming quit attempt (91%), followed by family/social pressures (28.1%) and cost (27.9%, particularly by smokers with psychotic disorders). Common pre-cessation concerns for the complete sample included: cravings (27.6%), stress (26.7%), and fear of failure (26%); participants with psychotic and anxiety disorders were most concerned about cravings, whereas the latter two concerns were more prominent for individuals with anxiety.

CONCLUSIONS

Findings reveal differences in the quit histories and concerns of smokers with or without psychiatric illness. Smokers with psychiatric illness are particularly vulnerable to relapse at times of stress and negative affect; interventions that emphasize alternative coping strategies and facilitate mood management are required.

Association of the manganese superoxide dismutase gene Ala-9Val polymorphism with age of smoking initiation in male schizophrenia smokers

Schizophrenia patients exhibit higher smoking rates than the general population. A growing body of evidence suggests that cigarette smoke impairs the antioxidant defense mechanisms, leading to oxidative damage. Manganese superoxide dismutase (MnSOD) is the major antioxidant in the mitochondria, catalyzing the metabolism of superoxide radicals to form hydrogen peroxide. Since the identification of a well-characterized functional polymorphism, Ala-9Val of MnSOD, a number of studies have evaluated the association between Val-9Ala and schizophrenia or cancer. In this study, we hypothesized that the functional polymorphism of MnSOD Ala-9Val was associated with smoking in patients with schizophrenia. This polymorphism was genotyped in 666 chronic male schizophrenia patients (smoker/never-smoker = 507/159) and 660 male controls (smoker/never-smoker = 360/300) using a case-control design. The cigarettes smoked per day (CPD) and smoking behaviors were evaluated by clinician-administered questionnaires and the Fagerstrom Test for Nicotine Dependence (FTND). The results showed no significant differences in MnSOD Ala-9Val genotype and allele distributions between the patients and healthy controls or between smokers and never-smokers in either patients or healthy controls alone. The smokers with the Ala allele started smoking significantly earlier (19.9 ± 5.8 vs. 21.7 ± 6.5 years, P = 0.005) only in patients. These results suggest that the MnSOD Ala-9Val polymorphism may not influence smoking status in a Chinese male schizophrenia population, but may influence the age at which smoking is started among schizophrenia smokers.

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.

Exploring Issues of Comorbid Conditions in People Who Smoke

Smoking affects comorbid disease outcomes, and patients with comorbid conditions may have unique characteristics that are important to consider when treating tobacco use. However, addressing tobacco in patients being treated for comorbid conditions is not a consistent practice. Recognizing the need for a "call-to-action" to address tobacco use in people with comorbid conditions, the Tobacco Treatment Network within the Society for Research on Nicotine and Tobacco (SRNT) convened a Comorbidities Workgroup to explore the relationship between smoking and comorbid disease to identify common themes including: the harms associated with continued tobacco use, the frequency of comorbid disease and tobacco use, the potential effect of comorbid disease on the ability to quit tobacco use, the association between tobacco use and suboptimal disease-specific treatment response, and evidence regarding potential approaches to improve addressing tobacco use in patients with comorbid disease. Five candidate conditions (psychiatric, cancer, cardiovascular, pulmonary, and human immunodeficiency virus infected patients) were explored. Across comorbid conditions, smoking adversely affects treatment efficacy and promotes other adverse health conditions. People with comorbid conditions who smoke are motivated to quit and respond to evidence-based smoking cessation treatments. However, tobacco cessation is not regularly incorporated into the clinical care of many individuals with comorbidities. Optimal strategies for addressing tobacco use within each comorbid disease are also not well defined. Further work is needed to disseminate evidence-based care into clinical practice for smokers with comorbid disease and addiction research should consider comorbid conditions as an important construct to explore.

IMPLICATIONS

This article explores how physical and psychiatric conditions may interact in the treatment of tobacco dependence, and discusses the need for smoking cessation as a critical component of comorbid condition management. Five common comorbid domains-psychiatric, cancer, pulmonary, cardiovascular, and human immunodeficiency virus (HIV)-are highlighted to illustrate how these different conditions might interact with smoking with respect to prevalence and harm, motivation to quit, and cessation treatment utilization and success.

When Free Is Not for Me: Confronting the Barriers to Use of Free Quitline Telephone Counseling for Tobacco Dependence

Remarkable disparities in smoking rates in the United States contribute significantly to socioeconomic and minority health disparities. Access to treatment for tobacco use can help address these disparities, but quitlines, our most ubiquitous treatment resource, reach just 1%-2% of smokers. We used community-based participatory methods to develop a survey instrument to assess barriers to use of the quitline in the Arkansas Mississippi delta. Barriers were quitline specific and barriers to cessation more broadly. Over one-third (34.9%) of respondents (n = 799) did not have access to a telephone that they could use for the quitline. Respondents reported low levels of knowledge about the quitline, quitting, and trust in tobacco treatment programs as well as considerable ambivalence about quitting including significant concerns about getting sick if they quit and strong faith-based beliefs about quitting. These findings suggest quitlines are not accessible to all lower socioeconomic groups and that significant barriers to use include barriers to cessation. These findings suggest targets for providing accessible tobacco use treatment services and addressing concerns about cessation among lower income, ethnic minority, and rural groups.

How can we promote smoking cessation in people with schizophrenia in practice? A clinical overview

OBJECTIVE

High rates of smoking and nicotine dependence are associated with increased physical comorbidity and premature death in people with schizophrenia. We conducted a clinical overview to establish how smoking cessation should be promoted in practice.

METHOD

Systematic clinical review of major electronic databases from inception till November 2014.

RESULTS

A growing body of evidence supports pharmacological interventions to assist smoking cessation. The most promising evidence is for bupropion with several meta-analyses demonstrating its effectiveness. Currently, there is limited evidence demonstrating the effectiveness of nicotine replacement therapy (NRT) and varenicline, although this is likely to be due to the paucity of research. There are no consistent data to suggest that pharmacological interventions increase adverse events. Behavioural and psychosocial interventions also demonstrate promise, particularly when combined with pharmacotherapy. Careful monitoring of antipsychotic levels (in particular clozapine) is essential, and the promotion of physical activity may be useful to negate potential weight gain and diabetes risk following smoking cessation.

CONCLUSION

Evidence from systematic reviews and meta-analyses suggests that smoking cessation interventions are effective in people with schizophrenia, although more long-term research is required. Promoting smoking cessation should be given utmost priority in clinical practice, and we offer practical strategies to facilitate this.

Smoking Cessation in Individuals With Serious Mental Illness: A Randomized Controlled Trial of Two Psychosocial Interventions

OBJECTIVE

Smoking among individuals with serious mental illness is a critical public health problem. Although guidelines recommend bupropion for these smokers, many do not want to use medications for smoking cessation, express ambivalence about identifying a "quit date," and do not have access to behavioral smoking cessation services integrated with mental health care.

METHODS

Individuals with serious mental illness who smoked 10 or more cigarettes per day (N = 178) were randomized to either a multifaceted behavioral group intervention or a supportive group intervention, both of which were integrated within outpatient mental health services at three VA medical centers. Participants attended twice-weekly meetings for 12 weeks, provided information on their smoking at each meeting, and completed baseline and post-treatment assessments conducted by an assessor who was blind to condition. Primary outcomes collected at post-treatment included 1-week abstinence, number of cigarettes smoked per day during the last week, and number of quit attempts during the treatment period. Outcomes examined for a subset of participants who attended at least one intervention meeting (n = 152) included smoking abstinence for 1-, 2-, and 4-week blocks during the treatment period. Analyses conducted on those participants who attended three or more intervention meetings (n = 127) included time to 50% reduction in the number of cigarettes smoked and time to first quit attempt.

RESULTS

Sixteen participants achieved abstinence (11.8%), smoking quantity was significantly reduced (baseline M = 15.2, SD = 9.8 to post-treatment M = 7.5, SD = 7.7, p <.0001), and most reported making a quit attempt (n = 88, 72.7%). There were no differences by study condition on any abstinence or reduction outcomes. Significant reductions in number of cigarettes smoked generally took place within the first two weeks; however, these reductions did not often translate into abstinence.

CONCLUSIONS

Many participants reduced their smoking and sampled quitting during the study. Implementing smoking cessation services in mental health treatment settings is feasible and, if delivered in line with best practices, either a behavioral or a supportive approach can be helpful. Future research should examine ways to facilitate the transition from reduction to abstinence. This study was part of a clinical trial registered as NCT #00960375 at www.clinicaltrials.gov.

Nicotine dependence in the mental disorders, relationship with clinical indicators, and the meaning for the user

OBJECTIVE

to identify the degree of nicotine dependence among patients with schizophrenia and other mental disorders hospitalized in a general hospital, correlating these indices with clinical indicators and the meaning for the user.

METHOD

the study was performed in the psychiatric unit of a general hospital, interviewing 270 patients with mental disorders using a questionnaire and the application of the Fagerstrom test. A descriptive statistical analysis of the data and thematic analysis of the content were performed.

RESULTS

among the 270 patients with mental disorders, 35.6% were smokers; of whom, 53.2% presented high or very high nicotine dependence. Of the 96 smokers, 32 (33.3%) were schizophrenic, among whom, 59.4% presented high or very high dependence. Higher levels of dependence were also found among the 59 elderly people (61.5%) and 60 subjects with somatic comorbidities (62.5%). Meanings of smoking for the subjects: helps to forget problems and face daily conflicts; alleviates side effects of the medications; self-control; distraction; part of life.

CONCLUSION

more intense tobacco dependence among schizophrenic patients is justified due to it helping them to cope with the difficulties of the disease. Nurses occupy a strategic position in the care.

Socio-demographic and clinical characteristics of heavy and non-heavy smokers among schizophrenia inpatients in a Chinese Han population

OBJECTIVE

Despite higher smoking rates in schizophrenia, few studies have explored the clinical-demographic correlates of different amounts of smoking exposure. Little is known about the association between smoking severity and clinical phenotypes in Chinese patients with schizophrenia.

MATERIALS AND METHODS

We investigated differences between heavy (≥1 pack/day) and non-heavy (<1 pack/day) smoking in 550 male inpatients with schizophrenia using clinician-administered questionnaires and the Fagerstrom Test for Nicotine Dependence. They also were rated on the Positive and Negative Symptom Scale (PANSS), the Simpson and Angus Extrapyramidal Symptom Rating Scale (SAES), and the Abnormal Involuntary Movement Scale (AIMS), as well as were assayed with laboratory tests and an electrocardiogram.

RESULTS

Heavy smoking prevalence was approximately 31 %. Compared to the non-heavy smokers, the heavy smokers were younger, more with paranoid subtype but less with disorganized subtype schizophrenia, smoked at an earlier age, fewer getting clozapine or all atypical antipsychotics together, and were taking larger doses of antipsychotic drugs. The heavy smokers scored significantly lower on the PANSS negative symptom subscore and total score, and also on the SAES and AIMS scores than the non-heavy smokers. In addition, heavy smokers displayed longer rate-corrected electrocardiographic QT intervals, but without any significant differences in other laboratory tests.

CONCLUSION

Our results suggest several clinical or demographic differences between the heavy and non-heavy smoking patients with schizophrenia in a Chinese population. Heavy smoking remains a general health risk for schizophrenia.

Smoking among individuals with schizophrenia in Korea: gender differences

OBJECTIVE

This study examined gender differences in smoking and quitting among individuals diagnosed with schizophrenia in Korea. In addition, the study investigated differences in caffeine use by gender and smoking status.

METHOD

An anonymous self-report survey was conducted with psychiatric inpatients.

RESULTS

Compared to males, females were less likely to be current smokers (P<.001) and more likely to be former smokers (P<.01). Females were also less likely to be daily caffeine users (P<.001). Having more years of education (P<.05) and higher nicotine dependence scores (P<.05) were associated with decreased odds of intending to quit smoking, whereas having more previous quit attempts (P<.01) was associated with increased odds. These findings were significant even after adjusting for gender. Smokers were more likely to be daily caffeine users (P<.001) than their non-smoking counterparts.

CONCLUSION

Nurses in Korea should play an active role in tobacco control for patients with schizophrenia by providing cessation counseling and educating the effect of caffeine use on cigarette consumption, while tailoring the service to gender differences found in this study.

Interventions for smoking cessation and reduction in individuals with schizophrenia

BACKGROUND

Individuals with schizophrenia smoke more heavily than the general population and this contributes to their higher morbidity and mortality from smoking-related illnesses. It remains unclear what interventions can help them to quit or to reduce smoking.

OBJECTIVES

To evaluate the benefits and harms of different treatments for nicotine dependence in schizophrenia.

SEARCH METHODS

We searched electronic databases including MEDLINE, EMBASE and PsycINFO from inception to October 2012, and the Cochrane Tobacco Addiction Group Specialized Register in November 2012.

SELECTION CRITERIA

We included randomised trials for smoking cessation or reduction, comparing any pharmacological or non-pharmacological intervention with placebo or with another therapeutic control in adult smokers with schizophrenia or schizoaffective disorder.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the eligibility and quality of trials, as well as extracted data. Outcome measures included smoking abstinence, reduction in the amount smoked and any change in mental state. We extracted abstinence and reduction data at the end of treatment and at least six months after the intervention. We used the most rigorous definition of abstinence or reduction and biochemically validated data where available. We noted any reported adverse events. Where appropriate, we pooled data using a random-effects model.

MAIN RESULTS

We included 34 trials (16 trials of cessation; nine trials of reduction; one trial of relapse prevention; eight trials that reported smoking outcomes for interventions aimed at other purposes). Seven trials compared bupropion with placebo; meta-analysis showed that cessation rates after bupropion were significantly higher than placebo at the end of treatment (seven trials, N = 340; risk ratio [RR] 3.03; 95% confidence interval [CI] 1.69 to 5.42) and after six months (five trials, N = 214, RR 2.78; 95% CI 1.02 to 7.58). There were no significant differences in positive, negative and depressive symptoms between bupropion and placebo groups. There were no reports of major adverse events such as seizures with bupropion.Smoking cessation rates after varenicline were significantly higher than placebo, at the end of treatment (2 trials, N = 137; RR 4.74, 95% CI 1.34 to 16.71). Only one trial reported follow-up at six months and the CIs were too wide to provide evidence of a sustained effect (one trial, N = 128, RR 5.06, 95% CI 0.67 to 38.24). There were no significant differences in psychiatric symptoms between the varenicline and placebo groups. Nevertheless, there were reports of suicidal ideation and behaviours from two people on varenicline.Two studies reported that contingent reinforcement (CR) with money may increase smoking abstinence rates and reduce the level of smoking in patients with schizophrenia. However, it is uncertain whether these benefits can be maintained in the longer term. There was no evidence of benefit for the few trials of other pharmacological therapies (including nicotine replacement therapy (NRT)) and psychosocial interventions in helping smokers with schizophrenia to quit or reduce smoking.

AUTHORS' CONCLUSIONS

Bupropion increases smoking abstinence rates in smokers with schizophrenia, without jeopardizing their mental state. Varenicline may also improve smoking cessation rates in schizophrenia, but its possible psychiatric adverse effects cannot be ruled out. CR may help this group of patients to quit and reduce smoking in the short term. We failed to find convincing evidence that other interventions have a beneficial effect on smoking in schizophrenia.

Treatment of tobacco dependence in people with mental health and addictive disorders

People with mental health and addictive disorders (MHADs) have higher rates of cigarette smoking, and less success in quitting smoking compared with the general population. Moreover, tobacco-related medical illness may be the leading cause of death in the MHAD population. We discuss the scope of this comorbidity, and approaches to the treatment of tobacco dependence in people with MHAD, including schizophrenia, mood disorders, anxiety disorders, and alcohol and substance use disorders. Finally, at the level of health systems, we emphasize the importance of integrated treatment of tobacco dependence in MHADs.

Clinical characteristics of heavy and non-heavy smokers with schizophrenia

Up to 50-90% of persons with schizophrenia smoke cigarettes. Limited data and theories suggest persons with schizophrenia may smoke for different reasons than persons without schizophrenia, making smoking cessation interventions particularly challenging in this population. Although health consequences of smoking are widely known, less information is available regarding characteristics of different amounts of smoking exposure in this population. This study was performed to investigate differences between heavy (≥ 1 pack per day) and non-heavy (<1 pack per day) smoking in patients with schizophrenia. Data from 745 patients, mean age 41.3+/-12.6 years, were drawn from a population of smokers admitted to State of Maryland inpatient mental health facilities (1994-2000). Records were reviewed to obtain demographic information, diagnosis, medication, smoking and substance use. 43% of patients were characterized as heavy smokers. Heavy and non-heavy groups did not differ in age, GAF, weight, or BMI. No differences were found in race, gender or antipsychotic treatments. However, patients smoking ≥ 1 packs per day were more likely to use other substances such as alcohol (χ(2)=6.67, df=1, p=0.01), cocaine (χ(2)=6.66, df=1, p=0.01), and other substances (χ(2)=9.95, df=1, p=0.003) compared to non-heavy smokers. No differences in cannabis or heroin use were found by smoking category. Controlling for age, race, sex and BMI, heavy smokers had higher total cholesterol (190.7(51.6)mg/dL) compared to non-heavy smokers (178.2 (43.0)mg/dL, p=0.03), but no differences were found in glucose or blood pressure. Heavy smoking may be a particular health risk in schizophrenia and significant efforts for smoking cessation or reduction are needed.