Smoking and mental health - NCSCT

More documents

Recommendations

Info

Smoking and mental health smokers with schizophrenia, indicate that varenicline is effective but recommend careful supervision and monitoring for exacerbation of psychiatric symptoms. 27 In terms of effectiveness this evidence is promising: the 12-week, randomised, double-blind, multicenter US trial, in which 84 patients received varenicline and 43 placebo, found abstinence rates of 19% versus 4.7% at 12 weeks, and 11.9% versus 2.3% at 24 weeks. 41 Other available evidence, although limited, provides further support: a 12-week, open-label, smoking cessation trial of varenicline combined with weekly group cognitive–behavioural therapy in 112 stable outpatients with schizophrenia 42 found 2-week and 4-week continuous abstinence rates of 47.3% and of 34% respectively, and significant reductions in smoking (measured by exhaled carbon monoxide) in those who did not succeed in quitting. A pilot study in eight outpatients with schizophrenia or schizoaffective disorder, 43 randomised to varenicline (1 mg twice a day) or placebo for 12 weeks delivered together with individual behavioural support, found that three of four participants treated with varenicline achieved continuous abstinence (weeks 8–12, verified with expired CO), compared with no participant in the placebo group. Smith et al, 44 in a study of 14 smokers with schizophrenia, found that treatment with varenicline led to some cognitive improvement, as well as to smoking reduction and reduced CO expired and cotinine levels. In a multicentre randomised trial of varenicline in over 500 smokers with major depression, reported at the time of writing only in a press statement, 4- week continuous abstinence rates at 3 months were 35.9% in those receiving varenicline, compared with 15.6% of participants receiving placebo, and 20.3% and 10.4% respectively at 1 year. 45 The study is reported to have found no difference in adverse events between treatment groups, although detailed comparisons are not provided. 45 Further randomised trials and surveillance data on use of varenicline in people with mental disorders are urgently required, but the available evidence suggests that, with careful supervision and monitoring, varenicline is likely to be safe and effective in this group. 5.2.5 Cautions on use of bupropion and varenicline In view of concerns over the occurrence of depression, suicidal thoughts, suicide attempts and completed suicides in patients taking varenicline, and updates from the Medicines and Healthcare products Regulatory Agency 46 and the US Food and Drug Administration (FDA), 47 current guidance from The Royal College of General Practitioners (RCGP) and The Royal College of Psychiatrists 31 in the UK recommends that both varenicline and bupropion be used under close, coordinated supervision by health professionals, especially in the first 2–3 weeks of therapy, that family members and caregivers be alerted to the potential for adverse effects, and that varenicline or bupropion be discontinued immediately in the event of any cause for concern. 88 © Royal College of Physicians 2013
Smoking cessation interventions for individuals with mental disorders 5 5.3 Cutting down on smoking, and other harm reduction strategies Promoting smoking reduction as an option for those who do not wish to attempt abrupt cessation has been controversial due to concerns that cutting down may provide false reassurance of reduced hazard, and perpetuate smoking by postponing a definitive quit attempt. For various reasons, including heavier smoking of the reduced number of cigarettes (compensation) and the exposure–response relationships between smoking and disease, the health benefits accrued from cutting down are likely to be disproportionately low in relation to reductions in the number of cigarettes smoked. A recent systematic review concluded that a substantial reduction in smoking seems to have a modest health benefit, although the long-term effects of smoking reduction are uncertain. 48 However, smoking reduction does yield substantial benefits in the general population by increasing the likelihood of a definitive quit attempt in the future. 49,50 Encouraging smokers to use NRT to cut down on smoking without a commitment to quit doubles the likelihood of a successful quit attempt. 51 Harm reduction strategies, 52 by which people who are otherwise unlikely or unwilling to quit are encouraged to substitute smoked tobacco with alternative sources of nicotine for long-term use, therefore offer substantial potential to prevent harm from smoking by both directly reducing the amount of smoke inhaled and making complete cessation more likely. This approach, which in addition to NRT embraces the potential of substitution using alternative nicotine devices such as electronic cigarettes, is endorsed in draft guidance from NICE 53 due for final publication in May 2013. Given the high levels of dependence on smoking and low perceived likelihood of quitting outlined in Chapter 2, harm reduction has evident major potential as a means to promote smoking cessation, and support smoke-free policies, in mental health settings. This potential is to date highly under-researched, and evidence on the effectiveness of harm reduction in SMI is currently limited, however, to analyses of secondary outcomes in a heterogeneous range of cessation studies 35–38,54,55 summarised in the following sections. 5.3.1 Behavioural interventions A study of a specialist smoking programme for SMI comprising 3 weeks of motivational enhancement therapy and 7 weeks of psychoeducation, social skills and relapse prevention training, compared with standard group therapy to achieve reductions in the numbers of cigarettes smoked, reported no difference in change in mean exhaled CO relative to baseline over 3 months. 29 This suggests that any reduction in cigarette consumption (which was not reported in the study) had been counterbalanced by compensatory smoking. Cigarette consumption was reduced, however, in a study of eight sessions of motivational interviewing and cognitive–behavioural therapy, which increased the likelihood © Royal College of Physicians 2013 89
Page 1 and 2:
PDF not for circulation Smoking and
Page 3 and 4:
Contents Members of the Tobacco Adv
Page 5 and 6:
Contents 4.4.3 Attention deficit hy
Page 7 and 8:
Contents 6.4.3 Staff knowledge 122
Page 9 and 10:
Contents 10.5 Tobacco policy and me
Page 11 and 12:
Contributors Anthony Aclet - Specia
Page 13 and 14:
Contributors Jill Williams - Associ
Page 15 and 16:
1 Mental disorders 1.1 What is a me
Page 17 and 18:
Mental disorders 1 1.3 Common menta
Page 19 and 20:
Mental disorders 1 1.4.4 Somatisati
Page 21 and 22:
Mental disorders 1 In addition to s
Page 23 and 24:
Mental disorders 1 not diagnosed un
Page 25 and 26:
Mental disorders 1 Similar to many
Page 27 and 28:
Mental disorders 1 12 Chang CK, Hay
Page 29 and 30:
Mental disorders 1 52 Young S, Toon
Page 31 and 32:
Smoking among people with mental di
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39 and 40:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52: Smoking among people with mental di
Page 53 and 54: Neurobiological and behavioural mec
Page 77 and 78: Epidemiology of the association bet
Page 99 and 100: Smoking cessation interventions for
Page 101: Smoking cessation interventions for
Page 125 and 126: 6 Population strategies to prevent
Page 127 and 128: Population strategies to prevent sm
Page 145 and 146: Smoking and mental disorders: speci
Page 153 and 154:
Smoking and mental disorders: speci
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
The economic cost of smoking in peo
Page 181 and 182:
Page 183 and 184:
Page 185 and 186:
Page 187 and 188:
Page 189 and 190:
Page 191 and 192:
Page 193 and 194:
Page 195 and 196:
Page 197 and 198:
Ethical and legal aspects 9 pose co
Page 199 and 200:
Ethical and legal aspects 9 less an
Page 201 and 202:
Ethical and legal aspects 9 patient
Page 203 and 204:
10 Summary and conclusions 10.1 Smo
Page 205 and 206:
Summary and conclusions 10 10.4 Smo
Page 207 and 208:
Summary and conclusions 10 although
Page 209 and 210:
11 Key conclusions and recommendati
Page 211 and 212:
Key conclusions and recommendations
Page 213 and 214:
Page 215:
show all

Smoking and mental health - NCSCT

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?