Smoking and mental health - NCSCT

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Smoking and mental health Table 5.1 continued Drug Effect of smoking Action to be taken on stopping Action to be taken on smoking relapse smoking Fluphenazine Reduces plasma levels by up to 50% On stopping, reduce dose by 25%. On restarting, increase dose to previous Monitor carefully over following dose 4–8 weeks. Consider further dose reductions. Fluvoxamine Plasma levels decreased by around Monitor closely. Dose may need to Dose may need to be increased to a third be reduced previous level Haloperidol Reduces plasma levels by around 20% Reduce dose by around 10%. On restarting, increase dose to previous Monitor carefully. Consider further dose dose reductions Mirtzapine Unclear, but effect probably minimal Monitor Monitor Olanzapine Reduces plasma levels by up to 50% Take plasma level before stopping. Take plasma level before restarting. On stopping, reduce dose by 25%. Increase dose to previous smoking After one week, repeat plasma level. dose over one week. Repeat plasma level Consider further dose reductions Tricyclic Plasma levels reduced by 25–50% Monitor closely. Consider reducing Monitor closely. Consider restarting antidepressants the dose by 10–25% over one week. previous smoking dose Consider further dose reductions Zuclopentixol Unclear, but effect probably minimal Monitor Monitor 94 © Royal College of Physicians 2013
Smoking cessation interventions for individuals with mental disorders 5 Smokers using these drugs would be expected to compensate their intake of nicotine from cigarettes to maintain blood levels, but starting these drugs in smokers using NRT for smoking cessation or abstinence is likely to reduce the efficacy of the NRT. Nicotine is not known to have any clinically significant interactions with other medications. 5.4.5 Interactions with caffeine Caffeine is also metabolised by CYP1A2, up to 60–70% faster in smokers than non-smokers, 61 and is one probable reason why cigarette smokers tend to drink more coffee than non-smokers. 69 Caffeine metabolism decreases within 3 or 4 days of stopping smoking and, if coffee consumption continues unchanged, can lead to symptoms including agitation, irritability or poor concentration which can be confused with or exacerbate symptoms of both nicotine withdrawal and mental disorders. High caffeine levels persist weeks or months after quitting smoking. 70 People who smoke, particularly those with high caffeine intakes, should therefore be advised to reduce caffeine when they quit smoking; this may be particularly important for smokers with schizophrenia, among whom very high serum caffeine levels have been reported. 71 5.4.6 Nicotine withdrawal symptoms Abrupt cessation or reduction in nicotine use in people who smoke regularly results in symptoms of nicotine withdrawal, which can include dysphoric or depressed mood, insomnia, irritability, frustration, anger, anxiety, difficulty concentrating and restlessness. 72 These symptoms tend to be more severe in smokers with SMI, 73–76 and their non-specificity can result in misattribution to mental disorders and inappropriate treatment responses. A study of smokers with schizophrenia admitted to a smoke-free hospital found higher levels of agitation in those with greater nicotine dependence, and a significant reduction in agitation in those who received a 21 mg nicotine patch relative to a placebo. 77 It is therefore particularly important to ensure that adequate doses of NRT are provided to people with mental disorders who smoke during quit attempts or other abstention from smoking. 5.4.7 Effects of antipsychotic medication on smoking cessation Antipsychotic medication can also influence smoking behaviour. Smokers using ‘atypical’ antipsychotics such as clozapine, as opposed to first-generation (‘typical’) treatments such as haloperidol, are more likely to quit smoking. 29 Clozapine treatment is also associated with reduced smoking, particularly in © Royal College of Physicians 2013 95
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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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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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