FACTORS ASSOCIATED with TOBACCO USE

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FACTORS ASSOCIATED with TOBACCO USE MENTAL
ILLNESS
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WHY do INDIVIDUALS with MENTAL ILLNESS SMOKE?
Smoking in adolescence is associated with
psychiatric disorders in adulthood, including
panic disorder, GAD and agoraphobia, depression
and suicidal behavior, substance use disorders,
and schizophrenia (Breslau et al., 2004 Weiser
et al., 2004 Goodman, 2000 Johnson et al., 2000)
MENTAL ILLNESS
SMOKING
Active psychiatric disorders are associated with
daily smoking and progression to nicotine
dependence (Breslau et al., 2004).
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FACTORS ASSOCIATED with TOBACCO USE in the
MENTALLY ILL
Psychological/Behavioral Conditioning effects
Coping tool Social interactions
Boredom
Biologic Pharmacologic Genetic
predisposition Alleviation of
withdrawal Pleasure effects
Weight control
Tobacco Use
Systemic Treatment Use of cigarettes for
reinforcement Failure to treat
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NEUROCHEMICAL and RELATED EFFECTS of NICOTINE
N I C O T I N E
? Pleasure, reward ? Arousal, appetite
suppression ? Arousal, cognitive enhancement ?
Learning, memory enhancement ? Reduction of
anxiety and tension ? Reduction of anxiety and
tension ? Mood modulation, appetite suppr.

• Dopamine
• Norepinephrine
• Acetylcholine
• Glutamate
• ?-Endorphin
• GABA
• Serotonin

Benowitz. Nicotine Tobacco Research
19991(suppl)S159S163.
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BIOLOGY of NICOTINE ADDICTION ROLE of DOPAMINE
Nicotine addiction
Nicotine stimulates dopamine release
is not just a bad habit.
Discontinuation leads to withdrawal symptoms.
Benowitz. (2008). Clin Pharmacol Ther 83531541.
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DOPAMINE REWARD PATHWAY
Prefrontal cortex
Dopamine release
Stimulation of nicotine receptors
Nucleus accumbens
Ventral tegmental area
Nicotine enters brain
Amygdala
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CHRONIC ADMINISTRATION of NICOTINE EFFECTS on
the BRAIN
Perry et al. J Pharmacol Exp Ther
199928915451552.
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acetylcholine
nicotine
Chronic Smoking Effects
nicotine receptor
pit
Source S.M. Stahl (2000). Essential
Psychopharmacology
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acetylcholine
nicotine
State of Nicotine Withdrawal
nicotine receptor
Source S.M. Stahl (2000). Essential
Psychopharmacology
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NICOTINE ADDICTION CYCLE
Reprinted with permission. Benowitz. Med Clin N
Am 19922415437.
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NICOTINE WITHDRAWAL EFFECTS

• Dysphoric or depressed mood
• Insomnia and fatigue
• Irritability/frustration/anger
• Anxiety or nervousness
• Difficulty concentrating
• Impaired task performance
• Increased appetite/weight gain
• Restlessness and impatience
• Cravings

Most symptoms peak 2448 hr after quitting and
subside within 24 weeks.
Refer to Withdrawal Symptoms Info Sheet
American Psychiatric Association. (1994). DSM-IV.
Hughes et al. (1991). Arch Gen Psychiatry
485259. Hughes Hatsukami. (1998). Tob Control
79293.
Not considered a withdrawal symptom by DSM-IV
criteria.
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GENETIC EFFECTS on NICOTINE METABOLISM
4.4
0.4
9.8
Nornicotine
Nicotine-1'- N-oxide
Nicotine
Nicotine
Nicotine glucuronide

1. CYP2A6
2. Aldehyde oxidase

4.2
80
Trans-3'- hydroxycotinine
Trans-3'- hydroxycotinine
Cotinine
Cotinine
13.0
33.6
Trans-3'- hydroxycotinine glucuronide
Cotinine glucuronide
12.6
Norcotinine
7.4
Cotinine- N-oxide
2.0
Reprinted with permission, Benowitz et al., 1994.
2.4
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WHAT is ADDICTION?

• Compulsive drug use, without medical purpose, in
  the face of negative consequences
• Alan I. Leshner, Ph.D.
• Former Director, National Institute on Drug Abuse
• National Institutes of Health

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MODEL of ADDICTION
Positive Reinforcement
Impulse control disorders
tension / arousal
regret / guilt / self-reproach
impulsive acts
TIME
Pleasure / relief / gratification
Compulsive disorders
anxiety / stress
obsessions
repetitive behaviors
relief of anxiety / relief of stress
Negative Reinforcement
Source GF Koob et al. (2004) Neuroscience and
Biobehavioral Reviews
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DSM-IV TOBACCO USE DISORDERS

• Nicotine Withdrawal
• Daily use of nicotine
• Abrupt cessation/reduction followed within 24 hrs
  by 4
• Depressed mood
• Insomnia
• Irritability
• Anxiety
• Difficulty concentrating
• Decreased HR
• Increased appetite
• Clinically significant impairment
• Not due to GMC

• Nicotine Dependence
• Maladaptive pattern of use with significant
  impairment manifested by 3 in 12-mos
• Tolerance
• Withdrawal
• ? Use
• Unsuccessful efforts to stop
• Time investment
• Loss of important activities
• Continued use despite knowledge of physical or
  psychological problems

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SYSTEMIC and TREATMENT FACTORS
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PSYCHIATRISTS in PRACTICE (Himelhoch Daumit,
2003)

• 1992-96 Natl Ambulatory Medical Care Survey
• 23 of psychiatric visits dropped from analysis
  because patient smoking status unknown
• For patients identified as smokers (N1610)
• Cessation counseling offered at 12 of visits
• Nicotine Dependence not diagnosed at any visit
• Nicotine replacement therapy never prescribed

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2005 AAMC PRACTICE SURVEY 801 PSYCHIATRISTS

• 62 Ask about tobacco
• 44 Assess readiness to quit
• 62 Advise cessation
• Assist
• NRT (23), other Rx (20)
• Cessation materials (13)
• 14 Arrange follow up
• 11 Refer to others

Psychiatrists the least likely to address tobacco
use with their patients relative to other
specialties (family medicine, internal medicine,
OB/GYN)
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PSYCHIATRY RESIDENTS (N105) ENGAGEMENT in the
5-As
Source Prochaska, Fromont et al., 2005 Acad
Psychiatry
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2008 American Psychiatric Nurses Association
Survey

• 85 Ask about tobacco
• 61 Refer patients for tobacco cessation
• Only 29 of respondents agencies offer tobacco
  cessation treatment

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Legacy Tobacco Documents

• Digital online library
• 10 million documents (50 million pages) from
  the major tobacco companies
• Related to their advertising, manufacturing,
  marketing, sales, and scientific research
  activities

http//legacy.library.ucsf.edu
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Tobacco Documents
Department of Health, Education, and
Welfare National Institute of Mental
Health Washington, DC August 4, 1980
I am writing to request a donation of cigarettes
for long-term psychiatric patientsbecause of
recent changes in the DHHS regulations, Saint
Elizabeth Hospital can no longer purchase
cigarettes for them.
I am therefore requesting a donation of
approximately 5,000 cigarettes a week (8 per day
for each of the 100 patients without funds).
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TOBACCO INDUSTRYS INTERESTS

• 1950s-1980s Beliefs that patients with
  schizophrenia, who smoke at high rates, immune to
  cancer

Prochaska, Hall Bero (2008). Schizophrenia
Bulletin
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TOBACCO INDUSTRYS INTERESTS

• 1960s1970s TI funded research on psychosomatic
  causes of cancer
• Proposed those who denied or repressed grief were
  more likely to develop cancer than those who
  expressed emotion
• longterm schizophrenics, outwardly calm, have
  no capacity for the repression of significant
  emotional events and no need to contain emotional
  conflict.
• Ultimately came under scrutiny for its
  scientific integrity

Prochaska, Hall Bero (2008). Schizophrenia
Bulletin
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TOBACCO INDUSTRYS INTERESTS

• 1964 1997 TI denied funding of 2 proposals to
  examine high rates of cancer in smokers with
  mental illness
• 1964 proposal denied in principle but referred
  to the study group on the psychophysiological
  aspects of smoking, for working over.
• Questioned whether some other kind of use could
  profitably be made of his data collection
  methods.

Prochaska, Hall Bero (2008). Schizophrenia
Bulletin
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Tobacco industry documents indicate the author
received funding from CTR and PM from at least
1977-1994 and contributed to papers conceived by
PM
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HOSPITAL SMOKING BANS
JCAHO ultimately yielded to massive pressure
from mental patients and their families, relaxing
a policy that called on hospitals to ban
smoking.
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LD 463 - An Act to Exempt Substance Abuse and
Psychiatric Patients from the Prohibition against
Smoking in Hospitals
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Source Legacy Tobacco Documents
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RJ Reynolds Project Sub Culture Urban Marketing
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CONTRIBUTING FACTORS SUMMARY

• Tobacco products are effective delivery systems
  for the highly addictive drug nicotine.
• Nicotine activates the dopamine reward pathway in
  the brain, which reinforces continued tobacco
  use.
• Nicotine dependence and withdrawal are DSM-IV
  psychiatric disorders.
• Tobacco dependence involves biological,
  psychological, social, systemic and treatment
  factors requiring a long-term multifaceted
  treatment approach.