Over the past 50 years, cigarette smoking rates in the United States have significantly decreased. However, these reductions have not been evenly distributed, with individuals suffering from psychiatric illnesses, including substance use disorders (SUDs), continuing to exhibit elevated smoking rates. Psychiatrists are in a unique position to address this disparity due to their skills in treating tobacco use disorder and their regular contact with patients who are more likely to smoke. This article advocates for the integration of tobacco use disorder evaluation and treatment into psychiatric practice.
Smoking Rates Among Individuals with Psychiatric Illness
Individuals with psychiatric illnesses have high rates of cigarette consumption and a heightened risk of dying from tobacco-related causes. According to the 2019 US National Survey on Drug Use and Health, 24% of individuals with a past-year major depressive episode and 36% of individuals with an SUD reported past-month cigarette smoking, compared to 16% of individuals without these conditions. In certain clinical settings, smoking rates are even higher. For instance, 62% of patients with schizophrenia in a large psychiatric hospital system in Maryland smoked cigarettes. Tobacco-related diseases accounted for 53% of deaths among individuals with schizophrenia, 48% among those with bipolar disorder, and 50% among those with depression admitted to California hospitals between 1990 and 2005. Additionally, 49% of individuals admitted with alcohol use disorder, 40% with cocaine use disorder, and 39% with opioid use disorder died from tobacco-related causes.
Impact of Smoking on Psychiatric Symptoms
Chronic cigarette exposure can lead to long-term health complications and may exacerbate psychiatric symptoms, prompting psychiatric evaluations. Nicotine withdrawal is characterised by irritability, dysphoria, cravings, insomnia, increased appetite, anxiety, difficulty concentrating, and restlessness. These symptoms overlap with those of several mood and anxiety disorders. Due to nicotine’s short half-life, withdrawal symptoms can develop rapidly and occur frequently without ongoing nicotine consumption. Understanding the association between nicotine withdrawal and other psychiatric symptoms is crucial for accurate symptom aetiology and empowering patients to improve their psychiatric health.
Barriers to Smoking Cessation in Psychiatric Practice
Despite high smoking rates among individuals with mental illness, the prescription of smoking cessation pharmacotherapy remains low. A study conducted through the Medical Expenditure Panel Survey found that in 2019, less than 2% of individuals were prescribed varenicline or nicotine replacement therapy, and 8.4% were prescribed bupropion. Psychiatrists possess the knowledge and skills to assist patients who smoke, using familiar techniques from smoking cessation counselling paradigms like the 5 As: ask, advise, assess, assist, and arrange.
Challenges and Misconceptions
Several factors contribute to the lack of prioritisation of smoking cessation in psychiatric practice. Psychiatrists and patients may fear that smoking cessation could destabilise other psychiatric conditions. In 2009, the US Food and Drug Administration issued black box warnings about serious neuropsychiatric events associated with varenicline and bupropion. However, a large phase 4 trial with 8,144 participants showed no significant increase in neuropsychiatric events among individuals with and without mental illness. Additionally, patients may view cigarette use as a coping mechanism for psychiatric symptoms. A Cochrane review found that smoking cessation did not worsen and might improve mental health symptoms, including anxiety and depression.
Role of Psychiatrists in Smoking Cessation
Psychiatrists should screen for tobacco use and other nicotine consumption, such as electronic cigarettes, as part of psychiatric assessments. If screening is positive, they should evaluate the contribution of smoking and nicotine withdrawal to psychiatric symptoms and offer smoking cessation pharmacotherapies and counselling. Continuing medical education can assist psychiatrists in providing this care, with resources available through organisations like the American Psychiatric Association.
Training and Education
Psychiatry residency programs play a crucial role in equipping trainees with the skills to assist patients with tobacco use disorder. Programs should consider treating tobacco use disorder through pharmacologic and nonpharmacologic approaches as a required competency. Residents should receive formal training on tobacco use and smoking cessation and gain experience in providing smoking cessation counselling and pharmacotherapy.
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