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Despite the higher rates of smoking by people with mental illness compared with those without mental illness, only a quarter of facilities that treat patients with substance use disorders in the United States offer nicotine replacement therapy or medication treatment, and two-thirds allow tobacco use on their grounds, explained session chair Michael Brus, M.D., a clinical instructor of psychiatry at Icahn School of Medicine at Mount Sinai, during the session “The Deadliest Drug Epidemic: How Psychiatrists and the Media Miss the Boat on Tobacco Addiction, and What to Do About It.” Brus called for psychiatrists to do more to address tobacco use in this population.
To help patients successfully quit tobacco, Jill Williams, M.D., director of the Division of Addiction Psychiatry at the Rutgers University-Robert Wood Johnson Medical School, said psychiatrists should regularly ask patients about their tobacco use, and if they do use tobacco, advise patients on the risks of such use and refer them to treatment such as behavioral counseling.
Psychiatrists should also strongly consider prescribing smoking cessation medications, including varenicline, which is underused despite strong evidence of safety and efficacy.
Brus highlighted a 2016 study known as EAGLES that found varenicline to be superior to bupropion and the nicotine patch in helping smokers achieve abstinence (the study did not show a significant increase in adverse psychiatric events in patients taking varenicline compared with those with nicotine patch or placebo). Yet in the three years since that study, prescription rates of varenicline have ticked up only marginally, Brus said.
Williams highlighted another study that found that varenicline could promote smoking abstinence even in patients whose initial goal was only to reduce their smoking levels. “There’s also evidence that varenicline can lessen dependence and reduce withdrawal symptoms, so prescribing this medication can be a useful harm-reduction strategy even in people not looking to quit,” she said.
For psychiatrists who may still have concerns with varenicline, Brus and Williams pointed out that combination nicotine replacement (combining a long-acting patch with rapid-acting lozenges or gum) has been shown to be as effective as varenicline when combined with counseling. The current data are inconclusive about whether a combination of varenicline plus nicotine replacement therapy promotes better abstinence than either treatment alone. There is emerging evidence that varenicline plus bupropion may elevate quit rates, but more research is needed.
For related information, see the Psychiatric News article “Psychiatrists Hold Key for Helping Patients Quit Tobacco” and the Psychiatric Services article “Low-Burden Strategies to Promote Smoking Cessation Treatment Among Patients With Serious Mental Illness.”
(Image: iStock/Kim_white)
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