People with schizophrenia have a considerable reduction in life expectancy compared to the general population (Osborn et al 2007; Lawrence et al 2013). A number of factors lead to cardiovascular disease (Osborn et al 2007; Lawrence et al 2013; Nielsen et al, 2010) one of which is smoking.

People with schizophrenia smoke at much higher rates and more heavily than the general population (Ruther et al 2014, Hartz et al 2014).

Stubbs et al (2015) carried out a review to assess the current cessation interventions available for individuals with serious mental illnesses and establish if any disparities currently lie in the delivery of these interventions.

Methods

The authors searched several electronic databases (Embase, PubMed, and CINAHL) using the following keywords: “smoking cessation”, “smoking”, “mental illness”, “serious mental illness” and “schizophrenia.”

Studies were eligible if they included individuals with a DSM or ICD-10 diagnosis of schizophrenia and reported a cessation intervention.

The authors included both observational and intervention studies as well as systematic-reviews and meta-analyses.

Results

Pharmacological interventions

• The evidence suggests Bupropion (Zyban) is an appropriate aid for smoking cessation, and there has been no data supporting concerns of worsening in psychiatric symptoms or suicide risk.
• Varenicline (Champix) studies appeared to support smoking cessation, although long-term RCTs are recommended. Additionally, one study noted suicidal feelings; therefore monitoring psychiatric symptoms is recommended. However, do also check out our recent blogs investigating the neuropsychiatric adverse events of varenicline:
  • Varenicline and the risk of neuropsychiatric adverse events and death (Thomas et al, 2015), Natasha Clarke, 15 Apr 2015
  • Varenicline, smoking cessation and neuropsychiatric adverse events (Gibbons and Mann, 2013), Meg Fluharty, 9 Jan 2014

 Non-pharmacological interventions

• The evidence for E-cigarettes was inconsistent, with the authors concluding more evidence was needed before clinicians consider e-cigarettes within mental health settings. Additionally, e-cigarette use in people with schizophrenia should have side effects monitored closely.
• There was little research on exercise in schizophrenia, but one study found a reduction in tobacco consumption.

Behavioural approaches

• Behavioural approaches such as offering smoking cessation advice alongside pharmacotherapy have been found successful with no harmful side effects.

Disparities in smoking cessation interventions

• An investigation of GP practices found individuals with schizophrenia did not receive smoking cessation interventions proportional to their needs.

Support while quitting

• People with serious mental illnesses experience more severe withdrawal symptoms compared to the general population, and therefore should be given extra support during cessation attempts (Ruther et al 2014).
• Psychiatrists should re-evaluate choice and the dose of antipsychotic medicine being given after abstinence from smoking is achieved. This is because of nicotine’s metabolic influence on antipsychotic medicine.
• Alongside smoking cessation, exercise should be promoted among people with schizophrenia to combat weight gain and the increased metabolic risk.

Discussion

In light of the findings, the authors suggest several steps for clinicians to help people with schizophrenia quit smoking:

• Patients’ current smoking status, nicotine dependency, and previous quit attempts should be assessed. Assessing nicotine dependency will help predict the level of withdrawal symptoms the patient is likely to experience upon quitting.
• Cessation attempts are best timed when the patient is stable. Patients should be thoroughly advised on the process needed to give them the best chance of quitting smoking, Thus, allowing the patient to formulate their quit plan and take ownership of their own quit attempt.
• Cessation counselling should be provided, particularly what to expect with withdrawal symptoms (e.g. depression and restlessness) and how to cope.
• Pharmacological support should be provided (Bupropion recommended) when there is even mild tobacco dependence.
• Clinicians should carefully monitor patients’ medication and fluxions in weight for a minimum of 6 months after quitting smoking, and when needed recommended exercise to combat weight gain.

The authors provide a well laid out summary of their findings, alongside some excellent suggestions for clinicians to consider on how to best promote cessation in practice.

However, it should be stressed that Stubbs et al (2015) only searched for high qualities studies and provided an overview of them –  this is not a systematic review or meta-analysis. They included several types of studies, set little inclusion criteria and listed no exclusion criteria. This is quite different from a systematic review with a meta-analysis, which would set stricter predefined search and eligibility criteria, which identify a set of studies all tackling the same question, thus allowing for the statistical pooling and comparison of these studies.

Links

Primary paper

Stubbs B, Vancampfort D, Bobes J, De Hert M, Mitchell AJ. How can we promote smoking cessation in people with schizophrenia in practice? A clinical overview. Acta Psychiatrica Scandinavica. 2015: 1-9. 
[PubMed abstract]

Other references

Osborn DPJ, Levy G, Nazareth I, Petersen I, Islam A, King MB. Relative risk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom’s General Practice Research Database. Arch Gen Psychiatry 2007;64:242–249.

Lawrence D, Hancock KJ, Kisely S. The gap in life expectancy from preventable physical illness in psychi- atric patients in Western Australia: retrospective analysis of population based registers. BMJ 2013;346: f2539-f.

Nielsen RE, Uggerby AS, Jensen SOW, McGrath JJ. Increasing mortality gap for patients diagnosed with schizophrenia over the last three decades – a Danish nationwide study from 1980 to 2010. Schizophr Res 2013;146:22–27.  
[PubMed abstract]

Ruther T, Bobes J, de Hert M et al. EPA guidance on tobacco dependence and strategies for smoking cessation in people with mental illness. Eur Psychiatry 2014;29:65– 82. 
[PubMed abstract]

Hartz SM, Pato CN, Medeiros H et al. Comorbidity of severe psychotic disorders with measures of substance use. JAMA Psychiatry 2014;71:248–254.