Smoking rates have increased and remained higher among patients with mental disorders when compared to those without these illnesses. This paper reviews literature on implementing smoking cessation among patients with psychiatric illnesses, while presenting statistics and findings of various scientific studies. The specific literature touches on high tobacco use rates and limited quitting attempts, successful methods, sustaining cessation effects, and barriers for practitioners and patients. In addition, the review will include the strengths and weaknesses of the evidence presented in the literature while identifying gaps and limitations.
The 5A’s smoking cessation model is the foundation of the quitting process at a healthcare center. The 5A’s are Ask, Advise, Assess, Assist, and Arrange (Martinez et al., 2017). The model involves five steps: asking patients about their smoking status, advising smokers to quit, assessing quitting willingness, assisting smokers through referrals and treatment, and arranging follow up to support cessation (Martinez et al., 2017). While the model is effective in identifying smokers and facilitating cessation, health workers only perform the first three steps and neglect the last two (Martinez et al., 2017). During assisting and arranging stages, the practitioners help smokers to receive various treatments and conduct follow up to ensure sustenance (Martinez et al., 2017). The use of the 5A’s model is effective in identifying smokers and initiating treatment and sustenance interventions.
Mental health patients are more prone to abusing drugs, including smoking. The National Institute on Drug Abuse (NIDA) (2020) established that 40% of American smokers are vulnerable populations with mental disorders (MD). Additionally, smokers with MD are reported to smoke more cigarettes per day than those without (NIDA, 2020). Individuals with schizophrenia and bipolar disorder report higher smoking rates than those with other MD (NIDA, 2020; Dickerson et al., 2018). According to Dickerson et al. (2018), patients with schizophrenia reported the highest smoking rates, followed by those with bipolar disorder in the analyzed data spanning across 18 years. Sixty-two percent of schizophrenia patients in the study group were current smokers, while 37% of bipolar disorder patients and 17% of patients without any MD were currently smoking (Dickerson et al., 2018). MD patients use smoking as a solution to mood changes caused by these illnesses.
Practitioners attest that MD smokers are more than those without mental disorders are and have lower rates of quitting attempts. In a study involving practitioners, Simonavicius et al. (2017) established that 80.4% of care providers agree that MD smokers are more dependent on nicotine than others are, while 56.7% said that these smokers have difficulties with cessation. The practitioners also reported that 32.2% of their smoking patients have MD, and 41.8% of all documented UK smokers have mental illnesses (Simonavicius et al., 2017). Attempts to quit smoking among mental health patients are limited and only initiated upon hospitalization (Hecht et al., 2019). In addition to limited quitting attempts, smokers with MD have a higher risk of relapse than those without (NIDA, 2020). With the increased smoking rates and lower cessation attempts among MD patients, practitioners must adopt the best methods to encourage and sustain abstinence.
Some of the methods of treating smoking or tobacco addiction are classified as medication, such as nicotine replacement therapy (NRT), bupropion, and varenicline; or behavioral. The types of NRT are gum, inhaler, lozenges, nasal spray, and transdermal patch (Flowers, 2017). The NRT method reduces negative and positive nicotine reinforcement by stabilizing the chemical levels in the blood. It is used for hospitalized smokers to limit withdrawal effects and recommended to those attempting to quit (Flowers, 2017). Bupropion is as effective as NRT methods but works by preventing the reuptake of dopamine and norepinephrine. Varenicline is more effective than NRT and bupropion, and it stimulates nicotic receptors, but the stimulation is less than that of nicotine (Taylor et al., 2020). For patients with MD, varenicline has been established to facilitated cessation and abstinence after two years without adverse effects on the patients’ mental conditions (Taylor et al., 2020). Taylor et al. (2020) found that smokers with mental health illnesses on varenicline had a 19% higher chance of quitting than those on NRT but the difference was smaller for patients without MD. Therefore, varenicline is the most successful medication for smokers with MD.
Behavioral methods include cognitive behavioral therapy (CBT), motivational interviewing, mindfulness, quit lines, telephone counseling, text messaging, and web-based support. Rogers et al. (2016) found that telephone counseling is specialized to suit each patient’s profile and led to 30-day abstinence after six months of intervention. When compared to quit lines, Rogers et al. (2020) established that telephone counseling was more effective as 26% on the call method quit smoking after six months against 18% on the quit lines. Patients choose a combination of web and text-based interventions instead of one of the two (NIDA, 2020). Counseling over the telephone and through the quit lines is more embraced and effective than text messaging and web-based support (Rogers et al., 2020; Hecht et al., 2019). Nevertheless, these technological methods are most effective when combined with medications.
CBT is widely used and studied as one of the best behavioral methods of smoking cessation. According to NIDA (2020), CBT involves patients’ training on trigger identification, relapse prevention techniques, and coping strategies. In a study involving smokers with and without MD, Loreto et al. (2017) found that combining CBT with other medical methods yielded the best results in cessation. More specifically, CBT used alongside nicotine transdermal patch and bupropion was the most effective, followed by a combination of the first two methods and the nicotine gum. Most importantly, the researchers noted that the methods were more effective on smokers with MD than with those without MD (Loreto et al., 2017). Although NRT alone increases quitting rates by 50% for smokers without MD, mental health smokers require highly intensive and engaging methods, necessitating the need to include group CBT to NRT treatment (Loreto et al., 2017). Therefore, group-based CBT used alongside NRT, bupropion, or varenicline is the most successful treatment method for cessation among mental health patients.
Since most smokers with MD begin the quitting process during hospitalization, there should be methods to sustain the abstinence and cessation process after discharge. Hecht et al. (2019) established that sustaining cessation effects requires follow up through telephone, interactive voice response, the web, and text messaging. The study subjects were grouped into those receiving sustained care and others under usual care. The sustained care group received various follow up efforts for eight weeks, while the usual care smokers only received health education while at the hospital (Hecht et al., 2019). The researchers also recommended enrolling smokers with MD into NRT treatment, which is widely accessible across the country (Hecht et al., 2019). Nevertheless, the follow up techniques will ensure sustenance of cessation among the patients.
Barriers to cessation exist on the provider and patient’s side. According to Schroeder et al. (2018), some of the barriers related to smokers include lack of motivation, stigma, comorbidity with mental illnesses, and the workload of treatment. The care providers lack enough resources to facilitate learning and improvement of treatment of smokers with MD (Simonavicius et al., 2017). Limited knowledge on treatment options for both patients and care providers hinders cessation efforts. Practitioners expressed little information relating to the 5A’s implementation, the connection between smoking and psychiatric disorders, tailoring cessation efforts to smokers with MD, and interaction between MD and smoking treatments (Simonavicius et al., 2017). Therefore, knowledge and resource limitations are leading barriers to cessation for both care providers and smokers.
The literature reviewed has strengths, weaknesses, gaps, and limitations available in most scientific studies. Most of the conclusions are drawn from real-world data instead of simulations, giving the results strong evidence through the validity of information. In addition, data from large national databases are representative of the general population and provide strong evidence. However, data sourced from public databases contain information from changing subjects, which could adversely affect the results. In addition, participants are samples of a bigger population and representation is not guaranteed. Self-reporting from participants poses challenges of honesty, sampling and response biases, introspective ability, and differences in interpreting the questions. Existing gaps in the literature include a study on retention efforts, genetics and tobacco use, and neurological connections to smoking and addiction. Research on these areas will improve prevention, treatment, and sustenance efforts and interventions.
References
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