Tobacco Use in Individuals with Co-occurRing Mental Illness

Providing tobacco use prevention and cessation treatment to clients coping with co-occurring disorders can be challenging; however, a foundation of research about how to meet the special needs of this population is being established.

• Schizophrenia
• Anxiety and Panic Disorders
• Depression/Negative Affect
• Bipolar Disorder

Schizophrenia

Up to 80% of individuals with schizophrenia smoke. Additionally, smoking cessation in this population is very uncommon, which may be due to the lack of motivation to quit.¹ Low quit rates may also be attributed to the exacerbation of undesirable psychological symptoms during withdrawal from tobacco use. Indeed, clients in psychosocial rehabilitation programs have reported that the regulation of affect and stress related to tobacco use is very important², thus supporting the use of tobacco as a way to self-medicate. Studies have mixed results concerning this hypothesis; in other studies, withdrawal from smoking had no significant effects on either the positive or the negative symptoms of schizophrenia.³

There is a direct neurochemical interaction between smoking and schizophrenia.

• Nicotine increases mesolimbicocorticol dopaminergeic activity in the nucleus accumbens and the prefrontal cortex. Activity in this area of the brain is associated with reinforcing activities such as eating, sex, and some drug use (e.g. cocaine and amphetamines). Individuals with schizophrenia suffer from a dysfunctional brain reward system, which could help explain the use of nicotine as a form of reward or self-medication to reduce the negative symptoms of schizophrenia.¹⁰
• Nicotine use can interact with the effects of antipsychotic medications.¹⁰ Therefore, changes in smoking status may necessitate the adjustment of antipsychotic medications.
  • Increased cigarette smoking can reduce adverse reactions to neuroleptics, supposedly because of increased medication metabolism.
  • Smokers needed, on average, 590 mg in chlorpromazine equivalents compared with 375 mg for non-smokers.
  • Individuals who were given haloperidol began to smoke more than they did prior to taking antipsychotic medications.
  • When patients were given therapeutically effective doses of clozapine, smoking decreased.¹⁰

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Anxiety and Panic Disorders

Empirical evidence suggests that a relationship between anxiety behavior and drug behavior exists; particularly with Panic Disorder.

• 19-56% of individuals with panic disorder smoke.
• In one study over 40% of those presenting for treatment of panic disorder smoked, while only about 19% of those with social phobia and 22% of those with obsessive-compulsive disorders smoked.⁴
• Because premorbid vulnerability to panic problems is related to coping-oriented smoking motives,⁴ there may be a unique relationship between smoking and panic that varies from the relationship of smoking with other anxiety disorders.
• Smokers (not in treatment) report higher rates of lifetime panic-attack criteria, panic disorder, and agoraphobia than nonsmokers.⁵
• Smoking is a risk factor for, and may maintain, panic attacks and panic disorder.⁶
• Although a direct causal link between smoking and panic has not been established, daily smoking does increase the risk of experiencing panic attacks, panic disorders, and agoraphobia.
• Adolescents who smoke 20 or more cigarettes a day are more likely than others to suffer from panic disorder and agoraphobia in young adulthood.⁶

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Depression/Negative Affect

• Although still a topic of debate, a meta-analysis of fifteen studies showed no significant differences in failure to quit smoking between smokers who had a history of depression and those who did not. This was true for both abstinence that was short-lived (> 3 months) or long-term (> or = 6 months).
• Nicotine and antidepressants may have some common properties.⁷
• Teen smokers who experience depressive symptoms are more likely to increase smoking than are their counterparts without a history of depression.

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Bipolar Disorder

The following characteristics in individuals with bipolar disorder are predictive of higher levels of smoking. They include:

• Rapid cycling;
• Comorbid psychiatric disorders and/or substance abuse;
• Current manic or depressive state.
• Higher rates of smoking were also associated with:
  • More frequent and severe lifetime depressive and manic episodes.
  • The use of atypical antipsychotic medications.⁸

A Harm Reduction Approach?

In light of how difficult it may be to help individuals with co-occurring disorders quit tobacco use, many researchers and clinicians are promoting the use of a harm reduction approach. If quitting use completely does not seem feasible, encouraging clients to attempt to limit their use may be more reasonable. Alternative nicotine providing systems should be offered, such as gums and patches.

However, some research suggests that by increasing the time dedicated to smoking cessation, quit rates can be similar to those in the general population. A meta-analysis pointed out that this was shown in studies that used both medication and psychoeducation in cessation programs.⁹