Smoking and mental health - NCSCT

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Smoking and mental health 491 NHS stop smoking service (NHS SSS) users also showed that those succeeding at a quit attempt experienced a marked reduction in anxiety symptoms compared with baseline, thus contradicting the common assumption that smoking is a stress reliever. 58 5.4.3 Weight gain Weight gain can be a significant problem among people with SMI, and reflects prevalent dietary patterns, low exercise levels and side effects of some medications. Concerns about additional weight gain resulting from quitting smoking are relevant in the general population 59 and especially so among smokers with SMI. 60 In the general population, smoking cessation is typically associated with a gain in weight of 5 kg or more relative to those who continue to smoke, and more in those who are already overweight. Similar outcomes might be expected in people with SMI, although the randomised trial literature on effects in SMI is not especially informative on this outcome; we are aware of only one study that has reported change in weight in participants with SMI, which reported no increase. 35 5.4.4 Interactions with treatment for mental disorders Metabolism of several psychotropic drugs is increased in cigarette smokers. This effect is not due to nicotine, but to inhaled polycyclic aromatic hydrocarbons in smoke, which induce cytochrome P450 (CYP) CYP1A2 isoenzymes 61 to metabolise many commonly used antipsychotics and antidepressants more quickly. Patients who smoke are therefore likely to need higher doses of these drugs to achieve similar blood levels to non-smokers, and in the event of stopping smoking need to reduce the doses used to compensate for this effect. This applies in particular to clozapine and olanzapine, two commonly used antipsychotic medications metabolised primarily by CYP1A2, 62 and pharmacokinetic studies have demonstrated more rapid clearance of olanzapine and lower clozapine concentrations in participants who smoke compared with those who don’t. 63,64 Adverse clinical outcomes arising from rapid increases in blood levels of these drugs after stopping smoking have been reported, 65,66 with symptoms including somnolence, hypersalivation, fatigue, extrapyramidal effects, delirium and seizures. 65,67 Clinical guidelines recommend reducing doses of these drugs by around 25% during the first week after stopping smoking, and monitoring blood levels before and at weekly intervals after stopping smoking until levels have stabilised. 68 Similar considerations apply to a range of other psychotropic drugs, for which recommendations are given in Table 5.1. Nicotine is metabolised predominantly by a different CYP enzyme, CYP2A6, which is induced by oral contraceptive medications and carbamazepine. 61,69 92 © Royal College of Physicians 2013
Smoking cessation interventions for individuals with mental disorders 5 Table 5.1 Prescribing guidelines for psychotropic drugs in smoking cessation 68 Drug Effect of smoking Action to be taken on stopping Action to be taken on smoking relapse smoking Benzodiazapines Plasma levels reduced by 0–50% Monitor closely. Consider reducing Monitor closely. Consider restarting (depends on drug and smoking status) dose by up to 25% over one week 'normal' smoking dose Carbamazepine Unclear, but smoking may reduce Monitor for changes in severity of Monitor plasma levels carbamazepine plasma levels to a adverse effects small extent Chlorpromazine Plasma levels reduced. Varied Monitor closely, consider dose Monitor closely, consider restarting estimates of exact effect reduction previous smoking dose Clozapine Reduces plasma levels by up to 50%. Take plasma level before stopping. Take plasma level before restarting. Plasma level reduction may be On stopping, reduce dose gradually Increase dose to previous smoking dose greater in those receiving valporate (over a week) until around 75% of over one week. Repeat plasma level original dose reached (ie reduce by 25%). Repeat plasma level one week after stopping. Consider further dose reductions Duloxetine Plasma levels may be reduced by up Monitor closely. Dose may need to Consider re-introducing previous smoking to 50% be reduced dose continued © Royal College of Physicians 2013 93
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PDF not for circulation Smoking and
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Contents Members of the Tobacco Adv
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Contents 4.4.3 Attention deficit hy
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Contents 6.4.3 Staff knowledge 122
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Contents 10.5 Tobacco policy and me
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Contributors Anthony Aclet - Specia
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Contributors Jill Williams - Associ
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1 Mental disorders 1.1 What is a me
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Mental disorders 1 1.3 Common menta
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Mental disorders 1 1.4.4 Somatisati
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Mental disorders 1 In addition to s
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Mental disorders 1 not diagnosed un
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Mental disorders 1 Similar to many
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Mental disorders 1 12 Chang CK, Hay
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Mental disorders 1 52 Young S, Toon
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Smoking among people with mental di
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Neurobiological and behavioural mec
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The economic cost of smoking in peo
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Ethical and legal aspects 9 pose co
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Ethical and legal aspects 9 less an
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Ethical and legal aspects 9 patient
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10 Summary and conclusions 10.1 Smo
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Summary and conclusions 10 10.4 Smo
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Summary and conclusions 10 although
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11 Key conclusions and recommendati
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Key conclusions and recommendations
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Smoking and mental health - NCSCT

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