1. Smoking in Special Populations: Psychiatric and Alcohol Use Disorders Eric Heiligenstein, M.D. Clinical Director, Psychiatry Service University Health Services Associate, CTRI University of Wisconsin-Madison

2. The 1981 R.J. Reynolds Tobacco Co. Segmentation Study Described smokers who smoked for Described smokers who smoked for “mood enhancement” “mood enhancement” “helps perk you up” “helps perk you up” “calm down” “calm down” “cope with stress” “cope with stress” Mangini v. R.J. Reynolds Tobacco Company, Civil Case No. 939359

3. Broad Complications of Smoking and Psychiatric Disorders Additive mortality risks Additive mortality risks Smoking and nicotine dependence Smoking and nicotine dependence Associated with nearly all psychiatric disorders Associated with nearly all psychiatric disorders Individuals with psychiatric diagnosis in past month Individuals with psychiatric diagnosis in past month Consume 45% of cigarettes smoked in U.S Consume 45% of cigarettes smoked in U.S Dierker, 2001 Dierker, 2001 Jorm, 1999 Jorm, 1999 Breslau, 2003 Breslau, 2003

4. Specific Complications of Smoking and Psychiatric Disorders Complicates treatment Complicates treatment Affects psychotropic blood levels (induces CYP1A2) Affects psychotropic blood levels (induces CYP1A2) Zyprexa Zyprexa Clozaril Clozaril TCA’s TCA’s Smokers experience more tardive dyskinesia Smokers experience more tardive dyskinesia Depressed smokers have higher suicide rates than depressed nonsmokers Depressed smokers have higher suicide rates than depressed nonsmokers Bruce, 1994 Bruce, 1994 Lohr, 1992 Lohr, 1992 Yassa, 1987 Yassa, 1987

5. Association of Smoking and Psychiatric Disorders Rates among specific diagnoses Rates among specific diagnoses General population General population 22-30% 22-30% Panic disorder Panic disorder 35% 35% Alcohol abuse Alcohol abuse 43% 43% Depression Depression 49% 49% Schizophrenia Schizophrenia 88% 88% Hughes, 1986 Hughes, 1986

6. Smoking Status According to Psychiatric Diagnosis US Population Current Smokers, % Lifetime Smokers, % Total10028.547.1 No mental illness 50.722.539.1 Ever mental illness 49.334.855.3 Any mental illness in past month 28.341.059.0 Adapted from Lasser, 2000

7. Smoking Rates Compared to the Number of Lifetime Psychiatric Diagnoses Adapted from Lasser, 2000

8. Nicotine Dependence and Mental Health Most prevalent comorbid diagnosis Most prevalent comorbid diagnosis Most deadly Most deadly Most costly Most costly Most treatable Most treatable Most overlooked Most overlooked

9. Fundamental Problems in Smokers with Coexisitng Psychiatric Disorders Both neurobiological and psychosocial factors reinforce use of nicotine Both neurobiological and psychosocial factors reinforce use of nicotinereinforce Lower rate of quit attempts Lower rate of quit attempts 30% vs. 42% 30% vs. 42% Higher tobacco relapse rates Higher tobacco relapse rates Feel excluded from mainstream cessation programs Feel excluded from mainstream cessation programs

10. Specific Problems For many people with chronic psychiatric disorders For many people with chronic psychiatric disorders Smoking is a major part of daily routine/structure Smoking is a major part of daily routine/structure Alleviates stigma Alleviates stigma Positive and negative freedoms Positive and negative freedoms Long considered integral part of psychiatric culture Long considered integral part of psychiatric culture WI Indoor Air Act WI Indoor Air Act Many clinicians believe that persons with psychiatric disorders are not able or willing to quit Many clinicians believe that persons with psychiatric disorders are not able or willing to quit

11. Neuropharmacology of Cigarette Smoke Major psychoactive component is nicotine Major psychoactive component is nicotine Binds to nicotinic acetylcholine receptors Binds to nicotinic acetylcholine receptors Endogenous agonist is acetylcholine Endogenous agonist is acetylcholine Receptors are widely distributed in the CNS Receptors are widely distributed in the CNS Cognitive processes Cognitive processes Emotions Emotions Reward pathways Reward pathways

12. Cigarettes and Neurotransmitters Cigarette smoke has MAOI properties Cigarette smoke has MAOI properties Nicotine acts as a neuromodulator Nicotine acts as a neuromodulator Dopamine Dopamine Serotonin Serotonin Norepinephrine Norepinephrine GABA GABA Glutamate Glutamate Acetylcholine Acetylcholine

13. Nicotine and Mood Possesses transient mood-elevating properties Possesses transient mood-elevating properties Reinforcing qualities mediated by ability to raise central dopamine levels Reinforcing qualities mediated by ability to raise central dopamine levels Quattrocki, 2000 Quattrocki, 2000

14. Nicotine and Cognition Improves working memory, attention, information processing Improves working memory, attention, information processing Prevents the normal decline in cognitive functioning seen with sleep deprivation Prevents the normal decline in cognitive functioning seen with sleep deprivation Enhances recall of information Enhances recall of information Rusted, 1994 Rusted, 1994

15. Smoking and HRQL Heavy smokers Heavy smokers Score lower than the 36th percentile on mental health dimensions (SF-36) Score lower than the 36th percentile on mental health dimensions (SF-36) Have more anxiety and depressive symptoms Have more anxiety and depressive symptoms Have greater limitations in social functioning and emotional roles (SF-36) Have greater limitations in social functioning and emotional roles (SF-36) Wilson, 1999 Wilson, 1999

16. Smoking and Depression Depression (current) associated with Depression (current) associated with Inability to quit smoking Inability to quit smoking Increased likelihood of smoking relapse Increased likelihood of smoking relapse Depression (past/current) leads to more severe nicotine withdrawal symptoms Depression (past/current) leads to more severe nicotine withdrawal symptoms High risk for relapse in first week High risk for relapse in first week Female risk>male Female risk>male Quattorocki, 2000 Quattorocki, 2000 Niaura, 1999 Niaura, 1999

17. Smoking and Depression Depression (past) associated with Depression (past) associated with Delayed increase in symptoms of depression following a quit attempt Delayed increase in symptoms of depression following a quit attempt Risk remains high for 6 months Risk remains high for 6 months Pomerleau, 2001 Pomerleau, 2001

18. Link Between Depression and Smoking Adapted from Kendler KS, 1993

19. Smoking and Anxiety Disorders Heavy smoking associated with higher risk of developing Heavy smoking associated with higher risk of developing Agoraphobia Agoraphobia GAD GAD Panic disorder Panic disorder Increased risk for relapse during early stages of quit attempt Increased risk for relapse during early stages of quit attempt Breslau, 2004 Breslau, 2004 Amering, 1999 Amering, 1999

20. Smoking and Alcohol Use Individuals are three times as likely to smoke if >5 drinks per week Individuals are three times as likely to smoke if >5 drinks per week 80% of smokers consume tobacco when drinking 80% of smokers consume tobacco when drinking Dawson, 2000 Dawson, 2000

21. Smoking and Alcohol Dependence At least 80% alcoholics smoke (3 times > than general pop.) At least 80% alcoholics smoke (3 times > than general pop.) Over 72% of alcoholics are heavy smokers (9% of general pop.) Over 72% of alcoholics are heavy smokers (9% of general pop.) Increased urge to drink among alcoholic smokers when they smell cigarettes Increased urge to drink among alcoholic smokers when they smell cigarettes Dawson, 2000 Dawson, 2000

22. Links Between Smoking and Alcohol Alcohol appears to increase the reward value of smoking Alcohol appears to increase the reward value of smoking Increases time spent smoking Increases time spent smoking Possible cross tolerance of nicotine and alcohol Possible cross tolerance of nicotine and alcohol Smoking decreases rate of gastric emptying Smoking decreases rate of gastric emptying Absorption of alcohol delayed Absorption of alcohol delayed Glautier, 1996 Glautier, 1996

23. Cessation Treatment for Alcohol Users Standard cessation treatments are effective Standard cessation treatments are effective No evidence of increased use of other substances during cessation treatment No evidence of increased use of other substances during cessation treatment Alcohol abstinence days greatest for those who quit smoking Alcohol abstinence days greatest for those who quit smoking Saxon, 2003 Saxon, 2003 Kohn, 2003 Kohn, 2003

24. Abstinence Rates for Various Formats No help: 7% No help: 7% Advice to quit: 10.2 % Advice to quit: 10.2 % Placebo: 13% Placebo: 13% Nicotine patch: 17% Nicotine patch: 17% Nicotine gum: 23% Nicotine gum: 23% Bupropion: 30% Bupropion: 30%

25. The “5 A’s” for Brief Intervention Ask about tobacco use Ask about tobacco use Systematically identify all tobacco users at every visit Systematically identify all tobacco users at every visit Advise to quit Advise to quit Strongly urge all tobacco users to quit in a clear strong personalized manner Strongly urge all tobacco users to quit in a clear strong personalized manner Assess willingness to make quit attempt Assess willingness to make quit attempt U.S. Department of Health and Human Services, 2000

26. The “5 A’s” for Brief Intervention Assist in quit attempt Assist in quit attempt Help the patient with a quit plan Help the patient with a quit plan Arrange follow up Arrange follow up U.S. Department of Health and Human Services, 2000

27. Antidepressants and Smoking Cessation Bupropion/NOR Bupropion/NOR Effective intervention independent of codiagnosis Effective intervention independent of codiagnosis SSRI/bupropion SSRI/bupropion Appears effective in smokers with comorbid depression Appears effective in smokers with comorbid depression Chengappa, 2001 Chengappa, 2001

28. Necessary Mental Health Care System Interventions Systematic identification processes that mesh with a non-medical practice style Systematic identification processes that mesh with a non-medical practice style Educational efforts for providers that emphasize the detrimental effects of smoking on mental health Educational efforts for providers that emphasize the detrimental effects of smoking on mental health Integration of cessation efforts with primary mental health treatments Integration of cessation efforts with primary mental health treatments Address emotional/behavioral comorbidity that effect cessation efforts in primary care settings Address emotional/behavioral comorbidity that effect cessation efforts in primary care settings