Smoking addiction treatment should be included in the care plans for mentally ill patients with tobacco dependence.

In a new study, clinical psychologist and lead author Brian Hitsman, of Northwestern University Feinberg School of Medicine, recommended an integrated care model to help mental health patients quit smoking. The method, combining drugs and psychological therapy, addresses the tobacco dependence of mentally ill smokers.

The review appeared in a recent issue of the Canadian Journal of Psychiatry.

In this Q&A, Hitsman explained his recommended smoking cessation method and why mental health care professionals should consider it.

Q: Why did you decide to focus on the mentally ill for this tobacco addiction review?

A: Smokers with mental illness have been underserved when it comes to tobacco dependence treatments both clinically as well as in the tobacco addiction research field. They just haven’t gotten the attention. The thinking has been that they can’t quit and that if you get them in your clinical trial they won’t show up so what’s tended to happen is that this population has been excluded from treatments.

Q: In your review, what did you learn about treating the tobacco dependence of those with mental health disorders?

A: Across these subgroups of people with mental illness, it became apparent that there were certain treatments that were more effective than others. It’s the combination of a medication called bupropion, which is marketed as Zyban, and is one of the first-line medications for the treatment of tobacco dependence, and intensive cognitive behavioral treatment or psychological therapy incorporated with motivational interventions that was most effective.

Q: Why do some mental health providers hesitate to administer a smoking cessation treatment alongside their current health plans?

A: We saw in surveys that, when mental health providers were asked about what they do with their patients who smoke, they would tend to report that they encourage them to continue. They say that it’s their only source of pleasure or they feel that their conditions would worsen if they ask them to stop. I guess the general fear is that if you banned smoking then you would lose control of all your patients.

Q: Why do they believe that treating tobacco dependence would be disruptive to their patients’ care?

A: Smokers with mental illness tend to smoke more so their withdrawal might be more severe. One of the things that could have happened is that when smokers quit smoking, the withdrawal symptoms could have been confused with a worsening of their psychiatric condition. The withdrawal is characterized by emotional symptoms—people get irritable, depressed, anxious, intense—and a lot of these symptoms are the same symptoms that characterize people with mental illness.

Q: How did you conclude that a smoking plan would not be disruptive?

A: We looked at randomized control trials that measured psychiatric symptoms across smoking treatments and we simply looked at whether symptoms increased, stayed the same or decreased. Half of them showed no change. The other half actually showed improvements. Not one of them actually showed a worsening of psychiatric symptoms.

Q: Are mental health professionals already trained to incorporate smoking cessation treatment into their psychiatric care plans?

A: I think they might be overwhelmed. To be fair, they have a lot going on. But, certainly, they can be trained. There’s really good evidence now that you don’t need an M.D. or Ph.D. to provide smoking cessation treatment.

Q: Why are the patients’ current mental health providers the ideal people to administer this tobacco dependence treatment?

A: They’re the ideal people because they have the most regular contact with the patients. They’re already seeing these people on a regular basis for medication management or psychotherapy. It just makes it also cost-effective for the patients. It’s also more efficient because they’re already dealing with psychological issues and tobacco dependence certainly relates to the person’s psychopathology.