6 myths and facts about tobacco use disorder in people with mental health and substance use disorders Mary.f.brunette@dartmouth.edu Associate Professor Psychiatry, Geisel School of Medicine 2015

Myth #1 MYTH: People must smoke to manage symptoms of mental illness or substance use disorder FACT: People with mental illness do not need to smoke to manage their mental illness. People with substance use disorder do not need to smoke to avoid using other substances. FACT: People with mental illness smoke in response to the urge to smoke and to reduce withdrawal symptoms

Withdrawal symptoms Nicotine withdrawal can occur after Daily use of tobacco/nicotine for at least a few weeks If daily nicotine users (more than 5 cigarettes/day) abruptly stop or reduce tobacco/nicotine, withdrawal symptoms can occur and peak in 1-4 days Dysphoric or depressed mood Irritability, frustration, anger Anxiety Insomnia Difficulty concentrating Restlessness Decreased heart rate Increased appetite or weight gain

MYTH #2 MYTH: People with mental health and substance use disorders don’t want to quit FACT: Most smokers with these disorders know that smoking is bad for them and try to quit, but they they have more difficulty quitting, so they feel discouraged and ambivalent. Treatment improves their outcomes. FACT: Many studies show that people with mental illness and addiction respond to education and motivational counseling with improved motivation to quit and use treatment for cessation Brunette 2013; Prochaska 2014’

MYTH #3 MYTH: Motivational interviewing doesn’t work FACT: Motivational counseling that helps people weight the pros and cons of smoking increases their interest in quitting and willingness to try cessation treatment.

MYTH #4 MYTH: People with mental illness and addiction can’t quit FACT: Research shows they can quit when they use cessation treatment (medication and counseling) 14 studies in schizophrenia 6 studies in bipolar disorder Dozens studies in depression and anxiety disorders Dozens in substance use disorders Cold turkey efforts are not very successful; meds and nicotine replacement therapy with counseling improves outcomes People have the most success if they are at their baseline for mental illness symptoms and are starting to get clean from substances

MYTH #5 MYTH: Nicotine replacement therapy is harmful FACT: Nicotine replacement therapy used as indicated is not harmful. FACT: Nicotine replacement therapy reduces uncomfortable withdrawal symptoms while people change their smoking habit FACT Smoke from tobacco, not nicotine, contains many chemicals that cause multiple diseases

IT’S THE Toxins in smoke THAT cause CVD, cancer, lung disease, diabetes

MYTH #6 MYTH: Only primary care providers are equipped to treat tobacco use FACT: Mental health and addiction providers are well equipped. They have regular and more frequent access to these smokers, training in motivational and behavior change strategies. Also, Tobacco Use Disorder is a DSM-5 diagnosis

REVIEW: 6 FACTS about smoking & people with mental illness and substance use disorders People with mental illness and addiction smoke in response to urges and nicotine withdrawal. They can remain stable while quitting with treatment People with mental illness and addiction want to quit, but are often ambivalent and discouraged Motivational counseling can help people get motivated to quit and to use effective cessation treatment Nicotine replacement therapy is safe, prevents nicotine withdrawal symptoms, and improves people’s ability to give up cigarettes and quit smoking altogether Mental health and addiction treatment providers are well equipped to help people quit smoking

References Anthenelli RM, et al. Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. Lancet. 2016. doi: 10.1016/S0140-6736(16)30272-0. PubMed PMID: 27116918. Thurgood SL, McNeill A, Clark-Carter D, Brose LS. A Systematic Review of Smoking Cessation Interventions for Adults in Substance Abuse Treatment or Recovery. Nicotine Tob Res. 2015. PMID: 26069036. Tidey JW, Miller ME. Smoking cessation and reduction in people with chronic mental illness. BMJ. 2015;351:h4065. PubMed PMID: 26391240. Williams J, Stroup TS, Brunette MF, Raney L. Tobacco use and mental illness: A wakeup call for psychiatrists. Psychiatric Services. 2014;65(12):1406-8.