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Table o ContentsOverview1 AlarmingStatistics 1
2 AboutthisToolkit: 2
Whoisthistoolkitor?HowdoIusethistoolkit?
Tobacco Use and Mental Illness
1 SmokingandMentalIllness: 3 BiologicalPredispositions,PsychologicalConsiderations,
SocialConsiderations,Stigma
2 SpecicMentalDisorders: 4
Depression,Schizophrenia,OtherDisorders
3 TobaccoIndustryTargeting 5
Assessment and Intervention Planning
1 ReadinesstoQuitandStagesoChange: 7 StagesoChange,The5As(Flowchart,Actionsand
Strategies),The5Rs(AddressingTobaccoCessationor
TobaccoUserUnwillingtoQuit)
2 CulturalConsiderations: 13
RecommendationsorMentalHealthClinician,Resources
Smoking Cessation Treatment or Persons
with Mental Illness1 KeyFindings 152 ComponentsoSuccessulIntensiveInterventionPrograms 16
3 BehavioralInterventionsorSmokingCessation: 17
Overview,SANEprogram,MoreElementso
SuccessulCounseling
4 PrescribingCessationMedications: 19
Depression,Schizophrenia,BipolarDisorder
Relapse Prevention1 ComponentsoMinimalPracticeRelapsePrevention 23
2 ComponentsoPrescriptiveRelapsePrevention 23
Local and National Tobacco Cessation Resources 25
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Funding or this project was provided by:Tobacco Disparities Initiatives o the State Tobacco Education and Prevention
Partnership (STEPP), Colorado Department o Public Health and the Environment
The Tobacco Cessation Toolkit or Mental Health Providers was developed
by the University o Colorado at Denver and Health Sciences Center,
Department o Psychiatry:
Chad Morris, Ph.D.
Jeanette Waxmonsky, Ph.D.
Alexis Giese, M.D.Mandy Graves, MPH
Jennier Turnbull
For urther inormation about this toolkit, please contact:
Jeanette Waxmonsky, Ph.D
University o Colorado at Denver and Health Sciences Center
4455 East 12th Avenue, A011-11
Denver, Colorado 80220
Phone: 303.315.9155
Fax: 303.315.9343
Email: [email protected].
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Overview
1 AlarmingStatistics
2 AboutThisToolkit:
Whoisthistoolkitor?
HowdoIusethistoolkit?
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O V E R V I E W | 1
Why is a smokingcessation toolkit orpersons with mentalillnesses needed?
They need to quit.Consumersneedtobealivetorecoverrommental
illnesses.Smokingcessationisakeycomponento
consumer-driven,individualizedtreatmentplanning.
They want to quit.Peoplewithmentalillnesseswanttoquitsmokingand
wantinormationaboutcessationservicesandresources.(Morrisetal,2006)
They can quit.Peoplewithmentalillnessescansuccessullyquit
usingtobacco.(Evinsetal.,2005;Georgeetal.,2002).
Signicantevidenceshowsthatsmokingcessation
strategieswork.
Note:Throughoutthistoolkitthetermstobaccouse
andsmokingareusedinterchangeably.Althoughwedo
notspecicallyaddressspit-tobaccouse,thetoolkitis
generallyapplicabletospit-tobaccousers.
Id love to quit I just dont know how. John, age 45
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O V E R V I E W | 2
Alarming StatisticsApproximately 7.7 percent o
Colorados adult population has a major
mental illness.1
Forty-onepercentotheseindividualsusetobacco.
Theprevalenceosmokingamongpeoplewith
mentalillnessesisstartling.
By diagnosis:Majordepression 45-50percent
Bipolarmooddisorder 50-70percent
Schizophrenia 70-90percent
Americanswithmentalillnessesrepresentan
estimated44.3percentothetobaccomarket. 2
Americanswithmentalillnessesarenicotine
dependentatratesthataretwotothreetimes
higherthanthegeneralpopulation. 3
Becausepeoplewithmentalillnessesusetobacco
atgreaterrates,theysuergreatersmoking-related
medicalillnessesandmortality.4
About this toolkitWho is this toolkit or?Thistoolkitwasdevelopedorabroadcontinuum
omentalhealthproviders.Materialsareintended
ordirectproviders,aswellasadministratorsand
behavioralhealthorganizations.
How do I use this toolkit?Thetoolkitcontainsavarietyoinormationand
step-by-stepinstructionabout:
Lowburdenmeansoassessingreadiness
toquit
Possibletreatments
ReerraltoColoradocommunityresources
1] Morris et al., 2006
2] Grant et al., 2004, Lasser et al., 2000
3] Grant et al., 2004, Lasser et al., 2000
4] Grant et al., 2004
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Quick FactsMental Illnesses and Tobacco Use
7.1%otheU.S.populationhasapsychiatricillness;however,thispopulation
consumesover34.2%oallcigarettes.(Grantetal.,2004)
IntheU.S.,personswithmentalillnessesrepresentanestimated44.3%othetobacco marketandarenicotinedependentatratesthatare2-3timeshigherthanthegeneral population.(Grantetal.,2004;Lasser,2000)
InColorado,approximately7.7%otheadultpopulationhasamajormentalillnessand 41%otheseindividualsusetobacco.(Gieseetal.,2003)
Smokingcessationisakeycomponentoconsumer-driven,individualizedtreatment
planning.(Morrisetal.,2006)
Personswithmentalillnesseswanttoquitsmokingandwantinormationoncessation servicesandresources.(Morrisetal.,2006)
Personswithmentalillnessescansuccessullyquitusingtobacco.(Evinsetal.,2005; Georgeetal.,2002)
SmokingquitratesorindividualswithpsychiatricillnessareNOTsignifcantlylower thanthegeneralpopulation.(el-Guebalyetal.,2002)
Becausepersonswithmentalillnessesusetobaccoatgreaterrates,theysuergreater smoking-relatedmedicalillnessesandmortality.(Grantetal.,2004)
References:
El-GuebalyN,CathcartJ,CurrieSetal(2002).Smokingcessationapproachesorpersonswithmentalillnessoraddictivedisorders.
Psychiatric Services,53(9):1166-1170.
EvinsAE,MaysVk,RigottiNA,etal.(2001).Apilottrialobupropionaddedtocognitivebehavioraltherapyorsmokingcessationin
schizophrenia.Nicotine Tobacco Research,3(4):397-403.
GeorgeTP,VessicchioJC,TermineAetal.(2002b).Aplacebo-controlledstudyobupropionorsmokingcessationinschizophrenia.Biological Psychiatry,52(1):53-61.
GieseA,MorrisC,OlincyA(2003).Needsassessmentopersonswithmentalillnessesortobaccoprevention,exposure,reduction,
andcessation.ReportpreparedortheStateTobaccoEducationandPreventionPartnership(STEPP),ColoradoDepartmentoPublic
HealthandEnvironment.
GrantBF,HasinDS,ChouPS,StinsonFS,DawsonDA(2004).NicotinedependenceandpsychiatricdisordersintheUnitedStates:
resultsromthenationalepidemiologicsurveyonalcoholandrelatedconditions.Archives General Psychiatry,61(11):1107-1115.
LasserK,BoydW,WoolhandlerS,etal(2000).Smokingandmentalillness:apopulationbasedprevalencestudy. Journal o the
American Medical Association,284:26062610.
MorrisCD,GieseJJ,DickinsonM,Johnson-NagelN.(2006).PredictorsoTobaccoUseAmongPersonsWithMentalIllnessesina
StatewidePopulation.Psychiatric Services,57:1035-1038.
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TobaccoUseandMentalIllness
1 SmokingandMentalIllness:
BiologicalPredispositions
PsychologicalConsiderations SocialConsiderations
Stigma
2 SpecifcMentalDisorders:
Depression
Schizophrenia
OtherDisorders
3 TobaccoIndustryTargeting
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Smoking and mental illnesses:nicotine eects and other considerationsPeoplewithmentalillnesses:
usetobaccoathigherrates
arelesslikelytosucceedatcessationattempts
accessgeneralmedicalservicesandother
communityresourcesrelativelyinrequently
strugglewithstigmaonseverallevels
generallyexperienceagreaterburdenomorbidity
andmortalitythantheoverallpopulation.
Why do they smoke more?Researchersbelievethatacombinationobiological,
psychologicalandsocialactorscontributetoincreased
tobaccouseamongpersonswithmentalillnesses.
Biological predisposition
Personswithmentalillnesseshaveuniqueneurobiologicaleaturesthatmayincreasetheirtendencytousenicotine,
makeitmorediculttoquitandcomplicatewithdrawal
symptoms.
Nicotineaectstheactionsoneurotransmitters
(e.g.dopamine).Forexample,peoplewithschizophrenia
whousetobaccomayexperiencelessnegative
symptoms(lackomotivation,driveandenergy).
Nicotineenhancesconcentration,inormationprocessing
andlearning.(Thisisespeciallyimportantorpersons
withpsychoticdisordersorwhomcognitivedysunction
maybeapartotheirillnessorasideeecto
antipsychoticmedications).
Otherbiologicalactorsincludenicotinespositiveeectsonmood,eelingsopleasureandenjoyment.
Someevidencesuggeststhatsmokingisassociatedwith
areducedriskoantipsychotic-inducedParkinsonism.
T O B A C C O U S E a n d M E N T A L I L L N E S S | 3
Tobacco useand mental illness
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T O B A C C O U S E a n d M E N T A L I L L N E S S | 4
Psychological considerationsTobaccousemaytemporarilyrelieveeelings otensionandanxietyandisotenusedtocope
withstress.
Peopledevelopadailyroutineosmoking.
Social considerationsPeoplemaysmoketoeelpartoagroup.
Smokingisotenassociatedwithsocialactivities.
Personswithmentalillnessesmaynothavealot
oactivitiestokeepthembusy.Whentheyre
bored,theymaysmokemore.
Thesiteoasocialactivitymaysupport
tobaccouse.
StigmaProvidersotenthinkthatpeoplewithmental
illnessesareunabletoquitsmoking.Symptommanagementotentakesprecedence
overpreventivehealthmeasures.
Specifc mental disordersWhataresomeconsiderationsorsmokingcessationinregardtospecicmentaldisorders?
Depression
Amongpatientsseekingsmokingcessation
treatment,25-40percenthaveahistoryomajor
depressionandmanyhaveminordysthymic
symptoms.
Depressionhasbeenshowntopredictpoorer
smokingcessationrates.Considerstartingor
restartingpsychotherapyorpharmacotherapyor
depressioninpatientswhostatethatdepression
intensiedwithcessationorthatcessationcaused
depression.
Cognitivebehavioraltherapyordepressionandantidepressantshasbeenoundtoimprovesmoking
cessationratesinthosewithahistoryodepression
orsymptomsodepression.
Forasmokerwithahistoryodepressioncurrently
takingantidepressantmedication,itisimportantto
notethatsomeantidepressantlevelswillincrease
withsmokingcessation.
Stress is a big
trigger or me.I dont know how
to deal with stress. Cathi, age 32
What I did to keep rom
craving cigarettes or a while
is just to keep busy, being
with people, and talking andplaying games and working
and things like that. Thats
what helped me.
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Schizophrenia
Personswithschizophreniawhosmokemaybeless
interestedintobaccocessation,makingstrategies
toenhancemotivationtoquitespeciallyimportant.
Whenmentalhealthconsumerswithschizophrenia
dotrytostop,manyareunsuccessul;thus,
intensivetreatmentsareappropriateevenwith
earlyattempts.
Thehighprevalenceoalcoholandillicitdrugabuse
inconsumerswithschizophreniacanintererewith
smokingcessation.
Thebloodlevelsosomeantipsychoticscan
increasedramaticallywithcessation.Nicotine
withdrawalcanmimictheakathisia,depression,
dicultyconcentratingandinsomniaseeninconsumerswithschizophrenia.
Other psychiatric disorders
Thereisinsucientinormationtomakespecic
recommendationsabouttailoringtreatmento
smokingcessationtotheneedsosmokerswith
otherpsychiatricdisorders.
Ingeneral,whenmentalhealthconsumersmakean
attemptatsmokingcessation,theyshouldbe
ollowedcloselytomonitorormoreseverenicotine
withdrawal,exacerbationotheirpsychiatricdisorder
andpossiblesideeectsduetocessation-induced
increasesinmedicationlevels.
Methylphenidate(Ritalin)andd-amphetamine
(Dexedrine),stimulantscommonlyprescribedor
behavioralproblemsassociatedwithattentiondecit
hyperactivitydisorder(ADHD)increaserateso
smokingandthereinorcingeectsosmoking.
Methylphenidateandd-amphetamineuseinearlylie
leadstoincreasedoddsodailysmokinglaterinlie.
Tobacco industry targeting
By1977,smokerswerebecomingadownscalemarket.RJReynoldsnotedthatlesseducated,
lowerincome,minoritypopulationsweremore
impressionable/susceptibletomarketingand
advertising.Tobaccocompaniesbegantargeting
thesepopulations.Free cigarettes were
distributed to homeless shelters, mental
hospitals and homeless service organizations.
Cigaretteswerepurchasedorthementallyillandhomelesssothatconsumerswouldsmokeclean
cigarettes,notdirtycigarettesbutts.
Thetobaccoindustryhastargetedpsychiatric
hospitalsorsalespromotionsandgiveaways.
Theyhavemadenancialcontributionstohomeless
veteranorganizations,usingrelationshipsto
advancetheirpoliticalagenda.
T O B A C C O U S E a n d M E N T A L I L L N E S S | 5
Ive been schizophrenic since I was 14. I was told more less when I wentto the hospitals that cigarettes help control certain areas in my brain and
the way we unction out in society. I more or less became more o a
smoker because I was told it would help me with my illness. I was taught
more about it helping my illness than I was about cancer and stu
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T O B A C C O U S E a n d M E N T A L I L L N E S S | 6
Notes
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AssessmentandInterventionPlanning
1 ReadinesstoQuitandStagesoChange:
StagesoChange
The5As(Flowchart,ActionsandStrategies)
The5Rs(AddressingTobaccoCessationor
TobaccoUsersUnwillingtoQuit)
2 CulturalConsiderations:
RecommendationsorMentalHealthClinicians
Resources
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Readiness to quit and stages o changeTheStagesoChangeModel(alsoknownastheTranstheoreticalModel)illustratedbelowisuseulin
recognizingthatnicotinedependenceisachronic,
relapsingdisorderwithmosttobaccousersinthegeneral
populationrequiringvetosevenattemptsbeorethey
nallyquitorgood.Manypatientsdonotrealizethatit
usuallytakesseveralattemptstostopusingtobaccoand
willneedmotivationtoattempttoquititheyhavebeen
unsuccessulinthepast.Itisuseultothinkotobacco
cessationasaprocessratherthananevent.
Onceapersonhasbeenidentiedasatobaccouser,
hisorherreadinesstoquitcanbedetermined.This
isimportantbecausetobaccouserswhoarenot
consideringquittingappeartoneeddierentinterventions
thanthosewhoareambivalentaboutquittingorthose
presentlyinterestedinquitting.TobaccousersinthePrecontemplationstage(notconsideringquitting)canbe
movedtotheContemplationstagebyaskingconsumers
toconsiderthenegativeconsequencesotobaccouse
orthemandtheadvantagesotobaccocessation(this
inormationhastobepersonalized).Itisworthwhile
toactivelyencouragequittingandoersupportand
treatmentaswellasconveyingthemessagethatpersons
withmentalillnessescansuccessullyquitusingtobacco.
Stages o changePrecontemplation:Nochangeisintendedinthe
oreseeableuture.Theindividualisnotconsidering
quitting.
Contemplation:Theindividualisnotpreparedtoquitat
present,butintendstodosointhenextsixmonths.
Preparation:Theindividualisactivelyconsidering
quittingintheimmediateutureorwithinthenext
month.
Action:Theindividualismakingovertattemptstoquit.
However,quittinghasnotbeenineectorlongerthan
sixmonths.
Maintenance: The individual has quit or longer than
A S S E S S M E N T a n d I N T E R V E N T I O N P L A N N I N G | 7
Assessmentand intervention planning
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A S S E S S M E N T a n d I N T E R V E N T I O N P L A N N I N G | 8
The 5 As:
Ask, Advise, Assess, Assist and ArrangeTheU.S. Public Health Service Clinical Practice
Guideline: Treating Tobacco Use and Dependence
provideshealthcarecliniciansastrategyorsmoking
cessationtreatmentthatisbuiltaroundthe5As
(Ask,Advise,Assess,AssistandArrange).Knowing
thatprovidershavemanycompetingdemands,the
5Aswerecreatedtokeepstepssimple.
Ontheollowingpagesyouwillndasummaryo
theseeasilyimplementedsteps.
TheGuidelinerecommendsthatallpeopleentering
ahealthcaresettingshouldbeaskedabouttheir
tobaccousestatusandthatthisstatusshouldbe
documented.Providersshouldadvisealltobacco
userstoquitandthenassesstheirwillingnesstomakeaquitattempt.Personswhoarereadyto
makeaquitattemptshouldbeassistedinthe
eort.Followupshouldthenbearrangedto
determinethesuccessoquitattempts.
Theull5Asmodelismostappropriateoragencies
andorganizationsthathavetobaccocessation
medicationsand/orbehavioralservicesavailableorconsumers.Foragenciesandorganizationsthat
donothavetobaccocessationservicesreadily
available,werecommendtheuseothersttwo
As(askandadvise)andthenrefertoavailable
communityservices.Theull5Asmodel,aswellas
theabbreviatedask-advise-reermodelare
presentedinthefowchartandtablesatthebacko
thisbook.
ASK
AD
VIS
E
AS
SE
SSASS
IST
AR
RAN
GE
Tobacco dependenceand use (current or ormer)
is a chronic relapsing
condition that requiresrepeated interventions and
a systematic approach.
I you have limited time:
ASKADVISEREFER
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Strategies for Implementation
Clear:Asyourclinician,Iwanttoprovideyouwithsomeeducationabout
tobaccouseandencourageyoutoconsiderquittingtoday.
Strong:Asyourclinician,Ineedyoutoknowthatquittingsmokingisthemost
importantthingyoucandotoprotectyourhealthnowandintheuture.Theclinic
staandIwillhelpyou.
Personalized:Tietobaccousetocurrenthealth/illness,itssocialandeconomic
costs,motivationlevel/readinesstoquit,and/ortheimpactotobaccouseon
childrenandothersinthehousehold.
Seepatienteducationalbrochureatbackothismanual.
Action
Inaclear, strong and
personalizedmanner,
adviseeverytobaccouser
toquit.
Bemindultoadviseina
non-judgmentalmanner.
Action
Forconsumersinterestedin
quitting.
Strategies for Implementation
Provideinormationonlocalsmokingcessationresources.Youmayndlocal
resourcesathttp://www.co.quitnet.com/libraries/programs/.
Useproactivereerraliavailable:Requestwrittenconsumerpermissiontoaxtheir
contactinormationtotheColoradoQuitLineorotherprogram.Inormthepatient
thecessationprogramstawillcontactthem.
Action
Askeveryconsumerat
everyvisit,includinghospital
admissions,itheysmoke.
Strategies for Implementation
Withinyourpractice,systematicallyidentiyalltobaccousersateveryvisit.
Establishanocesystemtoconsistentlyidentiytobaccousestatusateveryvisit.
(Seeclinicexampleatendothissection.)
Determinewhatormotobaccoisused.
Determinerequencyouse.
Determinetobaccousestatus.
Makenoteoconsumersexposedtosecondhandsmoke.
Actions and Strategies or Mental Health Providers to Help Consumers Quit Smoking
A S S E S S M E N T a n d I N T E R V E N T I O N P L A N N I N G | 9
ASK
REFER
ADVISE
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ActionAssesswillingnesstomake
aquitattemptwithinthenext
30days.
Determinewiththepatient
thecostsandbenetso
smokingorhimorher.
Determinewherethepatient
isintermsothereadiness
tochangemodel.
Assesspastquitattempts
andpast/currentpsychiatric
symptomsorconsumers
wantingtoquit.
Strategies for Implementation
Assessreadinessorchange.Gotop.7tolearnhowtoassessreadinessorchange.
Itheconsumerisreadytoquit,proceedtoAssist(below)and/orarrangeormore
intensiveservicestohelpwiththequittingprocess.
Itheconsumerwillparticipateinanintensivetreatment,deliversuchatreatmentor
reertoanintensiveintervention(Arrange).
Itheconsumerisntreadytoquit,dontgiveup.Providerscangiveeective
motivationalinterventionsthatkeepconsumersthinkingaboutquitting.Conducta
motivationalinterventionthathelpsconsumersidentiyquittingaspersonallyrelevantandrepeatmotivationalinterventionsateveryvisit.
Foraddressingtobaccocessationwithtobaccousersunwillingtoquit,please
proceedtothe5Rsonpage12.
Fortheconsumerwhoiswillingtoquit:
Obtainasmokinghistoryandassessexperiencewithpreviousquitattempts:
Reasonsorquitting.
Anychangeinpsychiatricunctioningwhenheorshetriedtostop?
Causeorelapse(wasthisduetowithdrawalsymptomsorincreased psychiatricsymptoms?)
Howlongdidheorsheremainabstinent?
Priortreatmentintermsotype,adequacy(dose,duration),complianceand
consumersperceptionoeectiveness.
Expectationsaboututureattemptsandtreatments.
Determinewhetherthereareanypsychiatricreasonsorconcernaboutwhetherthis
isthebesttimeorcessation:
Istheconsumerabouttoundergoanewtherapy?
Istheconsumerpresentlyincrisis,oristhereaproblemthatissopressingthat
timeisbetterspentonthisproblemthanoncessationatthisvisit?
Whatisthelikelihoodthatcessationwouldworsenthenon-nicotinepsychiatric
disorder?Andcanthatpossibilitybediminishedwithrequentmonitoring,useo
nicotinereplacementtherapyorothertherapies?
Whatistheconsumersabilitytomobilizecopingskillstodealwithcessation?
Ithecopingskillsarelow,wouldtheconsumerbenetromindividualorgroup
behaviortherapy?
Istheconsumerhighlynicotinedependentordoestheconsumerhaveahistory
orelapseduetowithdrawalsymptomsorincreasedpsychiatricsymptoms?Iso, whichmedicationmightbeohelp?
Increasingreadiness/motivation:Iaconsumerwithpsychiatricillnessisnotreadyto
makeaquitattempt,enhancemotivationanddealwithanticipatedbarriersto
cessation.
Useproblemsolvingstrategies.
Increase monitoring o tobacco se
A S S E S S M E N T a n d I N T E R V E N T I O N P L A N N I N G | 1 0
ASSESS
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Action
Helptheconsumerwitha
quitplan.
Recommenduseoapproved
nicotinereplacementtherapy
(NRT)and/orcounseling
Strategies for Implementation
Set a quit date,ideallywithintwoweeks.
Tellamily,riendsandcoworkersaboutquittingandrequestunderstandingand
support.
Anticipatetriggersorchallengestoplannedquitattempt,particularlyduringthe
criticalrstewweeks.Theseincludenicotinewithdrawalsymptoms.Discusshow
theconsumerwillsuccessullyovercomethesetriggersorchallenges.
Removetobaccoproductsromtheenvironment.Priortoquitting,consumershould
avoidsmokinginplaceswheretheyspendalototime(e.g.work,home,car).Forconsumerswithcognitivediculties(e.g.memoryorattentiondecits)dueto
mentalillness,havethemwritedowntheirquitplan,sotheycanreertoitlater.
RecommendtheuseoNRTmedicationstoincreasecessationsuccess.
Discussoptionsoraddressingbehavioralchanges(e.g.cessationclasses,
individualcounseling,telephonecoachingromtheColoradoQuitLine)
Encouragepatientswhoarereadytoquitthattheirdecisionisapositivestep.
A S S E S S M E N T a n d I N T E R V E N T I O N P L A N N I N G | 1 1
ASSIST
Action
Scheduleollow-upcontact.
Strategies for Implementation
Timing.Followupcontactshouldoccursoonaterthequitdate,preerablywithin
therstweek.Asecondollow-upcontactisrecommendedwithintherstmonth.
Scheduleurtherollow-upcontactsasneeded.
Actionsduringollow-upcontact:
Congratulate success!Itheconsumerhasrelapsed,reviewthecircumstancesandelicitrecommitment
tototalabstinence.
Remindpatientthatalapsecanbeusedasalearningexperience.
Identiyproblemsalreadyencounteredandanticipatechallengesinthe
immediateuture.
AssessNRTuseandproblems.
Consideruseorreerraltomoreintensivetreatment.
Give positive feedback about the patients attempts to quit.
Individuals often cut down substantially on their tobacco use
before quitting, and this harm reduction needs to be recognized
and congratulated.
ARRANGE
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A S S E S S M E N T a n d I N T E R V E N T I O N P L A N N I N G | 1 2
The 5 Rs: Addressing Tobacco Cessation
or the Tobacco User Unwilling to Quit(From Treating Tobacco Use and Dependence.
Quick Reference Guide for Clinicians, October 2000.
U.S. Public Health Service.
www.surgeongeneral.gov/tobacco/tobaqrg.htm)
The5RsRelevance,Risks,Rewards,Roadblocks
andRepetition,aredesignedtomotivatesmokers
whoareunwillingtoquitatthistime.
Smokersmaybeunwillingtoquitdueto
misinormation,concernabouttheeectsoquitting
ordemoralizationbecauseopreviousunsuccessul
quitattempts.Thereore,ateraskingabouttobacco
use,advisingthesmokertoquitandassessingthe
willingnessothesmokertoquit,itisimportantto
providethe5Rsmotivationalintervention.
Relevance
Encouragetheconsumertoindicatewhyquittingis
personallyrelevant,asspecicallyaspossible.
Motivationalinormationhasthegreatestimpactiit
isrelevanttoaconsumersmedicalstatusorrisk,
amilyorsocialsituation(e.g.,havingchildreninthe
home),healthconcerns,age,genderandotherimportantpatientcharacteristics(e.g.,priorquitting
experience,personalbarrierstocessation).
Risks
Asktheconsumertoidentiypotentialnegative
consequencesotobaccouse.Suggestand
highlightthosethatseemmostrelevanttothem.
Emphasizethatsmokinglow-tar/low-nicotine
cigarettesoruseootherormsotobacco(e.g.,
smokelesstobacco,cigarsandpipes)willnot
eliminatetheserisks.
Examplesorisksare:
Acuterisks:Shortnessobreath,exacerbationo
asthma,harmtopregnancy,impotence,inertility
andincreasedserumcarbonmonoxide.
Longtermrisks:Heartattacksandstrokes,lung
andothercancers(larynx,oralcavity,pharynx,
esophagus,pancreas,bladder,cervix),chronic
obstructivepulmonarydiseases(chronicbronchitis andemphysema),longtermdisabilityandneed
orextendedcare.
Environmentalrisks:Increasedriskolungcancer
andheartdiseaseinspouses;higherrateso
smokinginchildrenotobaccousers;increased
riskorlowbirthweight,SuddenInantDeath
Syndrome,asthma,middleeardiseaseand respiratoryinectionsinchildrenosmokers.
Every time I need a pack o
cigarettes, thats taking
money out o my pocket.
You can see everybody
around here, people that
arent smoking, look how
much money they have.
People that are smoking arepretty much broke. I I could
quit smoking, Id have more
money to spend.
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A S S E S S M E N T a n d I N T E R V E N T I O N P L A N N I N G | 1 3
Rewards
Asktheconsumertoidentiypotentialbenetso
stoppingtobaccouse.Suggestandhighlightthose
thatseemmostrelevanttotheconsumer.
Examplesorewardsollow:
Improvedhealth
Foodtastesbetter
Improvedsenseosmell
MoneysavedBetterselimage
Home,car,clothing,breathsmellbetter
Nomoreworryingaboutquitting
Setagoodexampleorchildren
Havehealthierbabiesandchildren
Nomoreworryingaboutexposingothers
tosmoke
FeelbetterphysicallyPerormbetterinphysicalactivities
Reducewrinkling/agingoskin
Roadblocks
Asktheconsumertoidentiyimpedimentstoquitting
andnoteelementsotreatment(problemsolving,
medications)thatcouldaddressbarriers.
Typicalbarriersmightinclude:
Withdrawalsymptoms
Fearoailure
Weightgain
Lackosupport
Depression
Enjoymentotobacco
RepetitionRepeatmotivationalinterventionseverytimean
unmotivatedconsumervisitstheclinicsetting.
Tobaccouserswhohaveailedinpreviousquit
attemptsshouldbetoldthatmostpeoplemake
repeated quit attempts beore they are successul
Cultural ConsiderationsCulturalissuesshouldalsobeconsideredorthose
individualsodiverseracialandethnicbackgrounds
astobaccocessationassessmentandservicesare
oered.
Recommendations
KeyndingsromtheSurgeonGeneralsreport:
(1998SurgeonGeneralsReport,TobaccoUse
AmongU.S.Racial/EthnicMinorityGroups)
Intheourracial/ethnicgroupsstudied(Arican
American,AmericanIndian/AlaskaNative,Asian
American/PacicIslanderandHispanic),Arican
Americanmenbearoneothegreatesthealth
burdens,withdeathratesromlungcancerthatare
50percenthigherthanthoseoCaucasianmen.
Ratesotobaccorelatedcancers(otherthanlung
cancer)varywidelyamongmembersoracial/ethnic
groups.TheyareparticularlyhighamongArican
Americanmen.
Tobaccouseamongadolescentsromracialand
ethnicminoritygroupshasbeguntoincreaserapidly,
threateningtoreversetheprogressmadeagainstlungcanceramongadultsintheseminoritygroups.
CigarettesmokingamongAricanAmericanteens
hasincreased80percentoverthelastsixyears
threetimesasastasamongwhiteteens.
Thehighlevelotobaccoproductadvertisingin
racial/ethnicpublicationsisproblematicbecausethe
editorsandpublishersothesepublicationsmay
limitthelevelotobaccousepreventionandhealth
promotioninormationincludedintheirpublications.
Well, the frst thing is you have to decide is that youre really
committed to doing it and then you try over and over and overuntil you fnally get there, and eventually you get there.
But it takes a lot o time and its not easy. Sandy, age 37
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A S S E S S M E N T a n d I N T E R V E N T I O N P L A N N I N G | 1 4
Recommendations or Mental Health Clinicians
Whenworkingwithpersonswithmentalillnesseswhoarealsoodiverseracial/ethnicbackgrounds,themental
healthclinicianshould:
Ask,Advise,Assistand/orReerallpatientswithregardtotobaccocessation.Thereisacriticalneedto
delivereectivetobaccodependenceeducationandinterventionstoethnicandracialminoritieswith
mentalillnesses.
Usecessationinterventionsthathavebeeneectiveorpersonswithmentalillnesses(e.g.NRTorbuproprion
incombinationwithindividualorgroupcounselingthatemploysmotivationalinterviewingorcognitive- behavioralstrategies).Avarietyosmokingcessationinterventions(includingscreening,clinicianadvice,
sel-helpmaterialsandthenicotinepatch)havebeenproveneectiveortobaccocessationinminority
populations.
Beculturallyappropriate,refectingthetargetedracial/ethnicgroupsculturalvalues.Thismayincreasethe
smokersacceptanceotreatment.
Conveycessationcounselingorsel-helpmaterialsinalanguageunderstoodbythesmoker.
Resources
Formoreinormationabouttobaccouseandinterventionorracial/ethnicpopulationsinColorado,pleasesee
theollowingonlineresources:
ColoradoTobaccoDisparitiesStrategicPlanningWorkingGroup:http://ctdsp.amc.org/
ColoradoStateStateTobaccoEducationandPrevention(STEPP):http://steppcolorado.com
ColoradoMinorityHealthForumorInormationonReducingHealthDisparitiesinColorado:
http://www.coloradominorityhealthorum.org/
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Example for Clinic Screening for Tobacco Use
From the U.S. Department of Health & Human Serviceshttp://www.surgeongeneral.gov/tobacco/tobaqrg.pdf
ACTION STRATEGIESforIMPLEMENTATION
Implementanofce-widesystem Expandvitalsignstoincludetobacco
thatensuresthat,oreverypatientat useoruseanalternativeuniversal everyclinicvisit,tobacco-usestatus identifcationsystem.
isqueriedanddocumented.
VITALSIGNS
BloodPressure:
Pulse: Weight:
Temperature: RespiratoryRate:
TobaccoUse(circleone):CurrentFormerNever
Repeatedassessmentisnotnecessaryinthecaseotheadultwhohasneverused
tobaccoorhasnotusedtobaccoormanyyears,andorwhomthisinormationis
clearlydocumentedinthemedicalrecord.
Alternativestoexpandingthevitalsignsaretoplacetobacco-usestatusstickerson
allpatientchartsortoindicatetobacco-usestatususingelectronicmedicalrecords
orcomputerremindersystems.
C l d Q itLi R f l F
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ParticipantConsentforReleaseofInformationAuthorization to Release Inormation (refects the requirements o 45 C.F.R. 164.508 August 14, 2002)
I,___________________________________,givepermissiontomyhealthcareprovidertoreleasemy
name,phonenumber,anddateobirthtotheColoradoQuitLine(800-QUIT-NOW)quitsmoking/tobacco
programatNationalJewishMedicalandResearchCenter(contractorortheColoradoQuitLinecallcenter),
1400JacksonStreet,Denver,Colorado,80206.
ThePURPOSEothisreleaseistorequestthatNationalJewishMedicalandResearchCentermakean
initialphonecalltometodiscussparticipationintheColoradoQuitLineProgram.Iunderstandthe
inormationtobereleased,thepurposeothisrelease,andthattherearelawsprotectingconfdentialityo
inormation.Iunderstandthatoncereleased,myinormationmaybere-disclosed,andmaynolongerbe
protected.Iunderstandthatsigningthisormisnotaconditionoreceivingservices.
_________________________________________________________ Participant Signature Date
Thispatientmayusenicotinereplacementtherapy.
_________________________________________________________Provider Signature Date
For more NRT program information please go to http://www.steppcolorado.comor call 1.800.QUIT.NOW.
PLEASEFAXORMAILTHISSIGNEDFORMTO:
ColoradoQuitLineSpecialist Fax 1.800.261.6259
Mail ColoradoQuitLine
(Participantname)
ReferringProvider(stamp/label/writein)
Name
Clinic/Facility
Address
City/State/Zip
Phone#
Fax#*
*REQUIREDTORECEIVECONFIRMATIONOFREFERRAL
PatientInformation
Name_______________________________________
Address_____________________________________
City/State/Zip_______________________________
Phone#______________________DOB__________
Besttimeanddaytocall_____________________
DoyouneedTTY? YesNo
Mayweleaveamessage? YesNo
Colorado QuitLine Referral Form
1.800.QUIT.NOW(1-800-784-8669)FAX:800-261-6259
SignHere
SignHere
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SmokingCessationTreatmentorPersonswithMentalIllnesses
1 KeyFindings
2 ComponentsoSuccessulIntensive
InterventionPrograms
3 BehavioralInterventionsorSmokingCessation:
Overview
SANEProgram
MoreElementsoSuccessulCounseling4 PrescribingCessationMedications:
Depression
Schizophrenia
BipolarDisorder
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Key fndingsSmokingcessationmodelsorpersonswithmental
illnessesgenerallycombinenicotinereplacementtherapy
(NRT)withCognitiveBehavioralTherapy(CBT),atypeo
psychotherapythatocusesonchangingdysunctional
thoughts,emotionsandbehavior.
CBTprogramsthatproducethemostsuccessulquit
ratesorthementalhealthpopulationgenerallyhave
groupsoapproximately8-10individualsthatmeetonceaweekor7-10weeks.
Consumerswithschizophreniaseemtohavethehighest
successwhenCBTiscombinedwithNRTandstrategies
toenhancemotivation.Arandomizedcontrolstudyby
Bakeretal.(2006)oundthatatallollow-upperiods,
asignicantlyhigherproportionosmokerswitha
psychoticdisorderwhocompletedalltreatmentsessionswerecurrentlyabstinent,relativetoacomparisongroup
opersonsreceivingcareasusual,(pointprevalence
rates:3months,30.0%vs.6.0%;6months,18.6%
vs.4.0%;12months18.6%vs6.6%).Smokerswho
completedalleighttreatmentsessionswerealsomore
likelytohaveachievedcontinuousabstinenceatthree
months(21.4%vs.4.0%).
Thereisastrongdose-responserelationbetween
thesessionlengthoperson-to-personcontactand
successultreatmentoutcomes.Intensiveinterventions
aremoreeectivethanlessintensiveinterventionsand
shouldbeusedwheneverpossible.
Haugetal.(2005)oundthatorpeoplewithdepression,
smokingcessationwasbestpredictedbystageo
change,withthoseinpreparationenteringtreatment
morequicklythancontemplatorsorprecontemplators.
Thevariablesmostassociatedwithacceptingtreatment
werenotseverityosymptoms,butrathercurrentuseo
psychiatricmedicationsandperceivedabilitytosucceed
in quitting
Smokingcessation treatment or personswith mental illnesses
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Components o Successul Intensive
Intervention Programs:Intensivecessationinterventionsshouldincludethe
ollowing(romtheU.S.DepartmentoHealthand
HumanServices,2000):
Assessment
Assessmentsshouldensurethattobaccousersare
willingtomakeaquitattemptusinganintensive
treatmentprogram.Otherassessmentscanprovideinormationuseulincounseling(e.g.stresslevel,
presenceopsychiatricsymptoms,stressors,other
comorbidity).Personswithmentalillnesseswhoare
attemptingtoquitsmokingshouldbecareully
assessedandmonitoredordepressionandother
psychiatricsymptomsateveryocevisit.
Program clinicians Multipletypesocliniciansareeectiveandshould
beused.Onecounselingstrategywouldbetohave
amedical/healthcarecliniciandelivermessages
abouthealthrisksandbenetsanddeliver
pharmacotherapy,andbehavioralhealthclinicians
deliveradditionalpsychosocialorbehavioral
interventionslikecognitivebehavioraltherapy(CBT).
Program intensity
Becauseoevidenceoastrongdose-response
relationship,theintensityotheprogramshouldbe:
Sessionlengthlongerthan10minutes.
Numberosessions4ormore.
Totalcontacttimelongerthan30minutes.
Program ormat
Eitherindividualorgroupcounselingmaybeused.
Proactivetelephonecounselingalsoiseective.
Useoadjuvantsel-helpmaterialisoptional.
Follow-upassessmentinterventionprocedures
shouldbeused.
Type o counseling and behavioral therapies
Counselingandbehavioraltherapiesshouldinvolvepracticalcounseling(problemsolving/skillstraining),
aswellasintra-treatmentandextra-treatment
socialsupport.
Pharmacotherapy
Everysmokershouldbeencouragedtouse
pharmacotherapies,exceptinthepresenceo
specialcircumstances.Specialconsiderationshouldbegivenbeoreusingpharmacotherapy
withselectedpopulations(e.g.pregnancy,
adolescents).Theclinicianshouldexplainhow
thesemedicationsincreasesmokingcessation
successandreducewithdrawalsymptoms.
Therst-linepharmacotherapyagentsinclude:
bupropionSR,nicotinegum,nicotineinhaler,
nicotinenasalsprayandthenicotinepatch.(SeePharmacotherapiesSectiononp.19and
laminatedsheetatbackothismanual).
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Behavioral Interventions or
Smoking CessationUseobriepsychosocialinterventions,sel-helpand
supportivetherapyhavebeenshowntobeeective
withgeneralmedicalpatientsbutmaynotbe
sucientorconsumerswithpsychiatricproblems
(APA,1996).Additionally,peoplewithmental
illnessesotenhaveewersocialsupportsand
copingskills.Thereore,intensivebehavioraltherapy
shouldbeconsideredorthesepeopleevenintheearlyquitattempts.Whenpossible,themental
healthprovidershouldelicitconsumerpreerences
aboutgrouporindividualtherapy.Iaconsumerhas
aspecicissuethatmightunderminetobacco
cessation(e.g.problemswithassertiveness),the
mentalhealthprovidermightworkonthisissuein
individualtherapywhiletheconsumeralsoattends
grouptherapyortobaccocessation.
Cessationprogramsorpeoplewithmentalillnesses
includeabout7-10sessions.Typically,thereis
anintroductiontotobaccohistoryandprevalence
ouse
educationaboutthepropertiesonicotine,health
eectsonicotineandaddictivenatureonicotine
areviewothereasonswhypeoplesmokeeducationaboutwaysonecanquitsmoking,use
omedicationanddevelopmentoaquitplan.
Asnotedabove,additionalsessionsareuseulor
addressingissuesthatarepertinenttopersonswith
mentalillnesses(i.e.,developingcopingskillsor
stressandanxiety).
TheSANEprograminAustralia(Strasser,2001)
isoneeectivegroupcounselingprogramorpersonswithschizophrenia.Itinvolvesteaching
problemsolvingskillsandcognitive-behavioral
techniquestoaidsmokingreductionandcessation
maintenance.Thegroupconsistso10sessions,
runbytwotrainedacilitators.Thecontentconsists
otheollowing:
IntroductiontotheProgram
ReasonstoQuitBenetsoQuitting
UnderstandingWhyWeSmokeandWays
oQuitting
WithdrawalSymptoms
SocialSupport
DealingwithStressandAnxiety
CopingwithDepression
AssertivenessTrainingAngerManagement
Smoke-FreeLiestyle
DealingwithHighRiskSituations
More Elements o Successul Counseling
Furtherelementsosuccessulcounselingand
supportiveinterventionsareoutlinedintheollowing
tables(U.S.DepartmentoHealthandHuman
Services,2000).
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Practical counseling
treatment component
(problems solving/skills
training
Recognizedangersituations:
Identiyevents,stressors,
internalstatesoractivitiesthat
increasetheriskosmokingorrelapse.
Developcopingskills:
Identiyandpracticecoping
orproblemsolvingskills.
Providebasicinormation
aboutsmokingand
successulquitting.
Examples
Negativemood
Psychiatricsymptoms
Beingaroundothersmokers
DrinkingalcoholorusingdrugsExperiencingurges
Beingundertimepressure
Learningtoanticipateandavoidtemptation.
Learningcognitivestrategiesthatwillreducenegativemoods.
Accomplishingliestylechangesthatreducestress,improvequalityolieor
producepleasure.
Learningcognitiveandbehavioralactivitiestocopewithsmokingurges(e.g.
distractingattention).
Anysmoking(evenasinglepu)increasesthelikelihoodoaullrelapse.
Withdrawaltypicallypeakswithin1-3weeksaterquitting.
Withdrawalsymptomsincludenegativemood,urgestosmokeanddiculty
concentrating.
Inormationontheaddictivenatureosmoking.
Common elements o practical counseling
Additionally, sta and peer support are key actors in cessation counseling.
Some common elements o each:
Supportive treatment
component
Encouragethepatientinthe
quitattempt.
Communicatecaringand
concern.
Encouragetheconsumer
totalkaboutthequitting
Examples
Sharethateectivetobaccodependencetreatmentsarenowavailable.
Notethatone-haloallpeoplewhohaveeversmokedhavenowquit.
Communicatebelieintheconsumersabilitytoquit.
Askhowtheconsumereelsaboutquitting.
Directlyexpressconcernandwillingnesstohelp.
Beopentotheconsumersexpressionoearsoquitting,dicultiesexperienced
andambivalenteelings.
Askabout:
Reasonstheconsumerwantstoquit.
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Common elements o eliciting peer support and other resources
Supportive treatment
component
Trainconsumersinsupport
solicitationskills.
Promptsupportseeking.
Arrangeoutsidesupport.
Examples
Showvideotapesthatmodelskills.
Practicerequestingsocialsupportromamily,riendsandcoworkers.
Aidconsumerinestablishingasmoke-reehome.
Helpconsumeridentiysupportiveothers.
Calltheconsumertoremindhimorhertoseeksupport.Inormconsumersocommunityresourcessuchasquitlines.
Mailletterstosupportiveothers.
Callsupportiveothers.
Inviteotherstocessationsessions.
Assignconsumerstobebuddiesoroneanother.
Prescribing Cessation MedicationsUtilizetherequencyomentalhealthtreatmentvisits
asanopportunityormonitoringprogressin
smokingcessation.Additionally,smokingcessation
strategiesshouldbeintegratedandcoordinated
withtreatmentsormentalillnesses.
Sincepeoplewithmentalillnessesappeartohave
morewithdrawalsymptomswhentheystop
smokingthanthegeneralpopulation,theuseonicotinereplacementtherapy(NRT)eveninearly
cessationattemptsisrecommended.
TheoptimaldurationoNRTisnotknown.Some
individualsappeartorequirelong-termuseoNRT
(e.g.,6months),butalmostallindividuals
eventuallystopusingNRTandthedevelopmento
dependenceonNRTisrare.Thus,patientpreerenceshouldbethemajordeterminateorthe
durationoNRT(American Psychiatric Association
Practice Guidelines 2006: Treatment of Patients with
Substance Use Disorders,2ndEdition,p54).
Depression
Considerbuproprionandnortriptylineorconsumerswithdiagnosesodepression.
Bupropion-SRhasbeendemonstratedtobethe
mosteectiveindepressedpatients.Patientswho
usebupropion-SRduringasmokingcessation
programaremorelikelytobeabstinentatthequit
date.However,relapseishighollowingthe
discontinuationotreatment(Evins,etal.,2005;
George,etal.,2002).Additionally,bupropion-SRhashadadverseaectsonpatientswithbipolar
disorderand/orahistoryoeatingdisorders.It
shouldnotbeusedinthesepopulations(McNeill,
2004).Additionalresearchonsmokerswitha
historyodepressionsuggeststheuseulnessothe
nicotinetransdermalpatch(Thorsteinssonetal.,
2001)andnicotinegum(Kinnunenetal.,1996)or
short-termsmokingcessation.
Stronglyconsiderbehavioraltherapiessuchas
CognitiveBehavioralTherapy(CBT),assmokers
withdepressionarelikelytoailwithmoreminimal
interventions(Brownetal,2001).Improved
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Schizophrenia
Smokingcessationprogramsthatusethenicotinetransdermalpatch(NTP)demonstratethehighest
quitratesorpatientswithschizophrenia(Williams&
Hughes,2003)asitaidsinwithdrawalsymptoms.
WhentreatmentincludestheuseoNRTinpatients
withschizophrenia,Dalacketal.(1999)oundthat
dyskinesiasdecreasedduringabstinenceinthe
placebopatchcondition,butincreasedduring
abstinenceintheactivepatchcondition.
NRTisassociatedwithsmokingcessationrateso
27percentto42percentinsmokerswith
schizophrenia(Addingtonetal.,1998;Chouetal.,
2004;Georgeetal.,2000).Also,useonicotine
nasalspray,whichproducesthehigherplasma
levelsonicotine,isassociatedwiththereductiono
withdrawalandcraving(Williamsetal.,2004).
Incontrolledtrials,pharmacologicaltreatmentwith
sustained-release(SR)bupropionhasbeen
ecaciousinpromotingabstinenceinpersonswith
schizophrenia.Treatment-seekingsmokershave
shownsuccess(withshort-termabstinencerateso
11percentto50percent)withacombinationo
bupropionSRandcognitive-behavioraltherapy
(CBT)atboththe150mg/day(Evinsetal.,2001)
andthe300mg/daydoses(Evinsetal.,2005;
Gerogeetal.,2002).Bupropiontreatmentalso
seemstoreducethenegativesymptomso
schizophrenia(Weinberberetal.,2006).
Patientstreatedwithatypicalantipsychoticagents,
suchasclozapine(Clozaril),smokeless(Georgeet
al.,1995;McEvoyetal.,1999,1995)andhaveaneasiertimequitting(Georgeetal.,2002,2000)than
thosetreatedwithtypicalantipsychoticmedications.
However,smokingcessationcancauseachangein
plasmaconcentrationsopsychotropicagentsdue
to a decrease in the induction o cytochrome P450
(Modecate),haloperidol(Haldol),andolanzapine
(Zyprexa).Thereore,monitoringmedicationsideeectsmaybeneededduringtherstmonthater
quitting(Kalmanetal.,inpress;Ziedonisand
George,1997).Themetabolismorisperidone
(Risperdal)andquetiapine(Seroquel)doesnot
appeartobeaectedbysmoking(Strasser,2001).
Bipolar Disorder
Glassmanetal.(1993)oundthatpersonswithbipolardisorder(BD)mayalsobeatriskor
recurrenceodepressivesymptomsduringsmoking
cessation.Interestingly,personswithBDshowa
geneticlinkagetothea7nAChRnicotinicreceptor
locusonchromosome15similartothatoundor
personswithschizophrenia(Leonardetal.,2001).
Todate,therehavebeennoempiricallybased
treatmentspublishedorsmokerswithBD
(Weinberger,etal,2006).UseoNTPissuggested
orthispopulation.
Anxiety Disorders
Althoughpatientsreportthatsmokingreduces
depressionandanxiety,chronicnicotineusein
animalstudiesispositivelycorrelatedwithincreased
anxiety(Irvineetal.2001).Itisuncleartowhat
extentsmokersexperiencewithdrawalsymptoms
andmisinterpretareductioninnicotinewithdrawal
asanxietyrelie(ZiedonisandWilliams,2003).
Cinciripiniandcolleagues(1995)oundthatsmokers
withhighlevelsotraitanxietyreceivingbuspirone
(BuSpar)versusplaceboweremorelikelytohave
remainedabstinentattheendothetrialbutnotat
ollow-up.AsnotedbyWeinbergeretal.,(2006),a
placebo-controlledstudybyHertzbergetal.(2001)obupropionSRorsmokerswithposttraumatic
stressdisorder(PTSD)oundthatbupropionwas
welltoleratedandresultedinhigherratesosmoking
cessation(60percent)ascomparedtotheplacebo
(20 percent)
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Also,inastudyoveteranswithpost-traumatic
stressdisorderwhoweresmokersMcFallandcolleagues(2005)oundthatsmokerswhoreceived
tobaccotreatmentintegratedwiththeirpsychiatric
carewerevetimesmorelikelythansmokerswho
receivedseparatetreatmenttoreportabstinence
romsmokingninemonthsaterthestudy.The
smokersreceivingtheintegratedtreatmentwere
morelikelytouseNRTandtoreceivemore
smokingcessationsessions.Additionally,cognitivebehavioraltherapytechniquesthatincorporate
cognitiverestructuringandexposuretherapytohelp
personslearntotolerateandbecomemore
comortablewithphysicalsensationsmaybehelpul
topersonswithanxietydisorders(Morissetteetal.,
2007).
Substance Use Disorders
Notsurprisingly,concurrentuseoalcoholand/or
otherdrugsisanegativepredictorosmoking
cessationoutcomesduringsmokingcessation
treatment(Hughes,1996).Long-termquitrateso
smokersinearlyrecoverromsubstanceuse
disorders(SUDs)arelow,atapproximately
12percent(Kalman,1998;Sussman,2002).
However,personswithapasthistoryoalcoholism
donodiersignicantlyromcontrolsubjectsin
tobaccotreatmentoutcomes(Hayordetal.,1999).
Thecombinedeectsoco-occurringsubstance
abuseandsmokingbehaviorsappeartosignicantly
infuencethehighratesosmokingcessation
treatmentailure(Weinbergeretal.,2006).Thereare
ewstudiesopharmacotherapeuticinterventionsor
smokinginsubstanceabusers,butsomeevidenceexistssuggestingthatnicotinereplacementand
behavioralapproachesareeective(Burlingetal.,
1996;Shoptawetal.,1996).Areviewotobacco
cessationstudiesbyel-Guebalyetal.(2002)ound
that quit rates ranged rom seven percent to 60
publishedcontrolledstudiesusingbupropionSRin
smokerswithco-occurringSUDs,althoughthesestudiesareinprogress(Weinbergeretal.2006).
Thetimingosmokingcessationtreatmentor
substanceabusersremainscontroversial
(Weinbergeretal,2006).Somestudiesoundthat
concurrenttreatmentorsmokingandotherdrugs
appearsnottobeassociatedwithincreaseduseo
alcoholorotherdrugs(Burlingetal.,2001;Kalmanetal.,2004,2001).Josephetal.(2004)oundthat
whilepatientsinalcoholtreatmentareinterestedin
smokingcessation,participateintreatment,and
demonstratesuccess,theydidnotshowanybenet
romconcurrenttobaccocessationtreatment.
Inact,Josephetal.oundthatdrinkingoutcomes
wereworsewithconcurrenttobaccotreatment,
suggestingthattobaccocessationinterventions
shouldbeprovidedtopatientsaterintensivealcohol
treatmenthasbeencompleted.
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Notes
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RelapsePrevention1 ComponentsoMinimalPractice
RelapsePrevention
2 ComponentsoPrescriptive
RelapsePrevention
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Most relapses occur soon ater a person quits
smoking, yet some people relapse months oreven years ater the quit date. Relapse prevention
programs can take the orm o either minimal (brie)
or prescriptive (more intensive) programs.
Components o Minimal Practice
Relapse PreventionTheseinterventionsshouldbepartoeveryencounter
withaconsumerwhohasquitrecently.Congratulateeveryex-tobaccouserundergoingrelapseprevention
onanysuccess.Stronglyencouragethemtoremain
abstinent.Whenencounteringarecentquitter,useopen-
endedquestionsdesignedtoinitiateconsumerproblem
solvingsuchasHowhasstoppingtobaccousehelped
you?Encouragetheconsumersactivediscussionothe
topicsbelow:
Thebenets,includingpotentialhealthbenetsthatthe
consumermayderiveromcessation.
Anysuccesstheconsumerhashadinquitting(duration
oabstinence,reductioninwithdrawal,etc.).
Theproblemsencounteredorthreatsanticipatedto
maintainingabstinence(e.g.,depression,weightgain,
alcoholandothertobaccousersinthehousehold).
Components o Prescriptive
Relapse PreventionDuringprescriptiverelapseprevention,aconsumermight
identiyaproblemthatthreatenshisorherabstinence.
Specicproblemslikelytobereportedbyconsumersand
potentialresponsesollow:
Lack o support or cessationScheduleollow-upvisitsortelephonecallswith
theconsumer.
Helptheconsumeridentiysourcesosupportwithin
hisorherenvironment.
Reertheconsumertoanappropriateorganizationthat
Relapseprevention
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Negative mood or depression
Isignicant,providecounseling,prescribeappropriatemedications,orreertheconsumerto
aspecialist.
Strong or prolonged withdrawal symptoms
Itheconsumerreportsprolongedcravingorother
withdrawalsymptoms,considerextendingtheuse
oanapprovedpharmacotherapyoradding/
combiningmedicationstoreducestrongwithdrawalsymptoms.
Weight gain
Recommendstartingorincreasingphysical
activity;discouragestrictdieting.
Reassuretheconsumerthatsomeweightgain
aterquittingiscommonandappearstobe
sel-limiting.
Emphasizetheimportanceoahealthydiet.
Maintaintheconsumeronpharmacotherapy
knowntodelayweightgain(e.g.,bupropionSR,
nicotine-replacementpharmacotherapies,
particularlynicotinegum).
Reerconsumertoaspecialistorprogram.
Flagging motivation / eeling deprived
Reassureconsumerthattheseeelings arecommon.
Recommendrewardingactivities.
Probetoensurethattheconsumerisnot
engagedinperiodictobaccouse
Emphasize that beginning to smoke (even a
pu) will increase urges and make quitting
more difcult.
Notes
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____________________________________
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____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
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LocalandNationalTobaccoCessationResources
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STEPPHealthcareProviderWebSite
http://www.cohealthproviders.com
STEPP
http://www.steppcolorado.com
AmericanCancerSociety
http://www.cancer.org
AmericanHeartAssociationOColorado http://www.americanheart.org
AmericanLungAssociationoColorado
http://www.alacolo.org/
AmericanPublicHealthAssociation
http://www.apha.org/
CentersorDiseaseControlandPrevention
http://www.cdc.gov/tobacco
ColoradoClinicalGuidelinesCollaborative
http://www.coloradoguidelines.org/
ColoradoTobaccoEducationandPreventionAlliance
http://www.ctepa.org/
SocietyorResearchonNicotineandTobacco
http://www.srnt.org
SurgeonGeneral
http://www.surgeongeneral.gov/
Local andnational tobacco cessation resources
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Notes
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ToolkitReerences
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Notes
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LiteratureReview
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Literature reviewIndividual Studies
Yr of
Pub
2001
1998
2006
1996
2001
2000
Author
Acton,G.,Prochaska,J.,
etal.
Addington,J.,
el-Guebaly,N.,
etal.
Baker,A.,
Richmond,R.,Haile,M.,
etal.
Borrelli,B.,
Niaura,R.,
etal.
Brown,R,,
Kahler,C.,
Niaura,R.,
etal
Combs,D.&
Advokat,C.
Article Name
Depressionandstagesochangeor
smokinginpsychiatric
outpatients
Smokingcessation
treatmentorpatients
withschizophrenia
Arandomized
controlledtrialoasmokingcessation
interventionamong
peoplewithapsychotic
disorder
DevelopmentoMDD
duringsmoking-
cessationtreatment
Cognitive-behavioral
treatmentor
depressioninsmoking
cessation
Antipsychotic
medicationand
smoking pre alence
Setting/
Contact
Type
Outpatientpsychiatric
research
center;
Survey
Outpatient
psychiatric
research
center;
Facetoace
Outpatient
mentalhealthclinics
orresearch
center;
Facetoace
Facetoace
Facetoace
Inpatient;
Facetoace
Volume # /
Issue #
AddictiveBehaviors,
26(5)
AmericanJ
oPsychiatry,
155(7)
AmericanJo
Psychiatry,163(111)
JoClinical
Psychiatry,
57(11)
JoConsulting
&Clinical
Psych,69
Schizophrenia
Research,
46(2 3)
Intervention
Correlationalstudy:205psychiatricoutpatients
completedmeasureso
depression(PRIME-MD
andBDI-II)
50schizophrenic
outpatientswere
dividedinto5groups
whometor7weekly
smokingcessation
programsessions
298regularsmokers
withapsychoticdisorderwererandomly
assignedtoatreatment
conditionconsistingo
8individualonehour
sessionsomotivational
interviewingand
cognitivebehavioral
therapyorcontrol
(treatmentasusual)
144non-depressedSs
tooktheBDIandthe
HamiltonRatingScale
orDepression;txwas
fuoxetine
Smokersw/MDD
randomizedtostandard
CBTsmokingcessation
txorsmokingcessationtx+CBTtreatmentor
depression
Schizophrenicpatients
whosmokedand
ere either recei ing
Results
PatientswhohadneversmokedshowedlowerratesoMDDthan
thosewhohadsmoked;patients
inearlystagesochangedidnot
showmoreMDDordepressive
symptoms,butshowedmore
negativethoughtsabout
abstinence;suggestbuilding
smokingcessationinterventions
basedonthetranstheoretical
modelochangeorusew/
psychiatricpops.
42%opatientshadstopped
smokingattheendothe
groupsessions,16%remained
abstinentat3mo,and12%at6
mo.;nochangesineitherposor
negsymptomsoschizophrenia.
Asignicantlyhigherproportion
osmokerswhocompletedalltreatmentsessionsstopped
smokingateachotheollow-
uptimesthancontrols(point
prevalenceratesat3months:
30%vs6%;6months:18.6%
vs4%;12months18.6%
vs4%).
5Ssmetthresholdcriteriaor
MDD.
SmokerwithrecurrentMDDand
heavysmokerswhoreceived
CBT-Dweresignicantlymore
likelytobeabstinentthaninstandardtreatment.
Clozapinewasassociated
withasignicantlylower
incidence o smoking than either
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Yr of
Pub
1990
2002
1999
2005
2004
Author
Covey,L,
Glassman,A,
etal.
Covey,L,
Glassman,A,
etal.
Dalack,G.,
Becks,L.,
etal.
Evins,A.,
Cather,C.,
etal.
Evins,A.,
Rigotti,C.,
etal.
Article Name
Depressionand
depressivesymptoms
insmokingcessation
Arandomizedtrial
osertralineasa
cessationaidor
smokerswithahistory
omajordepression
Nicotinewithdrawland
psychiatricsymptoms
incigarettesmokers
withschizophrenia
Adouble-blind
placebo-controlled
trialobupropion
sustained-releaseor
smokingcessationin
schizophrenia
Two-yearollow-upo
asmokingcessation
trialinpatientswith
schizophrenia:
Setting/
Contact
Type
Facetoace
Facetoace
Outpatient
psychiatric
research
center;Facetoace
Recruited
rom
commu-
nitymental
health
centers;
Facetoace
Facetoace
Intervention
Investigationinto
resultsoabehaviorally
orientedsmoking
cessationprogram
showedsmokersw/
MDDhistoryhadlower
successrates
134smokerswith
historyoMDD
receivedSertraline
(n=68)ormatching
placebo(n=66)1wk
placebowashout,9wk
double-blind,placebo-
controlledtreatment
phaseollowedbya
9daytaperperiod,anda6mo.drugree
ollow-up;allreceived
intensiveindividual
cessationcounseling
during9clinicvisits
19outpatientsw/
schizophreniaor
schizoaective
disorder;1dayoadlibitumsmoking
ollowedby3days
oacutesmoking
abstinencewhile
wearing22mg/day
activeorplacebo
transdermalnicotine
patches,withareturn
to3daysosmoking
betweenpatch
conditions
bupropion-SRvs
placebo;andCBT
2yrollow-upto
bupropiontxw/CBT
Results
Firstweekrequencyand
intensityopsychological
symptoms,particularly
depressivemood,werehigher
amongsmokerswithpast
depression;interventions
shouldattempttoprevent
dysphoricsymptomsduring
acutewithdrawlperiodorMDD
smokers.
Sertralinetxproducedalower
totalwithdrawlsymptomscore
andlessirritability,anxiety,
craving,andrestlessnessthan
placebo;howevernosignicant
dierencebetweenthegroups.
Dyskinesiaswereoundtohave
decreasedduringabstinence
andplacebopatchtreatment,
butincreasedduringabstinenceandtheactivepatchconditions.
Ssinbupropiongrpweremore
likelytobeabstinentorthe
weekaterthequitdateand
attheendotheintervention;
Ssinthebupropiongrphada
higherrateo4-wkcontinuous
abstinence(wks8-12)anda
longerdurationoabstinence;
relapseishighollowingthe
discontinuation.
MoreSswereabstinentat
ollowupthanwereabstinentat
theendothetrial;decreased
smokingduringthetrialwas
Volume # /
Issue #
Comprehensive
Psychiatry,
31(4)
AmericanJ
oPsychiatry,
159(10)
Neuropsycho-
pharmacology,
21(2)
JoClinical
Psycho-
pharmacology,
25(3)
Clinical
Psychiatry,
65(3)
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Yr of
Pub
1995
2002
2000
1997
1993
1991
2004
Author
George,T.,
Sernyak,M.,
etal.
George,T.,
Vessicchio,J.,
etal.
George,T.,
Ziedonis,D.,
etal.
Ginsburg,J.,
Klesges,R.,
etal.
Glassman,A.,
Covey,L.,
etal.
Greeman,M.&
McClellan,T.
Haas,A.,
Munoz,R.,
etal.
Article Name
Eectsoclozapine
onsmokingin
chronicschizophrenic
outpatients
Aplacebocontrolled
trialobupropionor
smokingcessationin
schizophrenia
Nicotinetransdermal
patchandatypical
antipsychotic
medicationsor
smokingcessationin
schizophrenia
Therelationship
betweenahistory
odepressionand
adherencetoa
multi-componentsmoking-cessation
program
Smokingcessation,
clonidine,and
vulnerabilitytonicotine
amongdependent
smokers
Negativeeectsoa
smoke-reeruleonan
inpatientpsychiatry
service
Infuencesomood,
depressionhistory,and
treatmentmodalityon
outcomesinsmokingcessation
Setting/
Contact
Type
Facetoace
Facetoace
Facetoace
Facetoace
Facetoace
Inpatient;
Facetoace
Facetoace
Intervention
29schizophrenic
outpatients;clozapine
txvsTYPneuroleptics
bupropion-SRvs
placebo
Ssw/schizoor
schizoatreatedw/
NTP&w/eitherATYP
orTYPantipsychotics;
GTotheAmer
LungAssnorGTor
smokersw/schizothat
emphasizedmotivationenhancement,relapse
prevention,social
skillstraining,and
psychoeducation
13wkCBG&random
assignmentto
nicotinegum,appetite
suppressantgum,or
placebogum
Clonidine
Smokingbanon
inpatientunitsata
VeteransAairsmedical
center
549Ss(28%w/history
oMDD);CBTvs.HE
Results
Therewasasigdecreasein
reporteddailyciguseater
clozapinetx.
Bupropion-SRincreased
smokingabstinencerates;pos
sympnotaected,negsymp
reduced;ATYPuseenhance
smokingcessationresponsestoBUP.
EectsoNTParemodestin
schizophrenicpatients;
nodierenceinGTprograms;
ATYPmaybesuperiortoTYP
incombinationw/NTP
orsmokingcessationin
schizophrenicpatients.
GroupCBTisaneective
smoking-cessationprogram
orwomenwithahistory
odepressionwhoarenot
currentlydepressed.
MDDpredicttxailure;an
increasedriskorpsychiatric
complicationsatersmoking
cessationwasapparentamong
smokerwithMDD,particularly
bipolar.
20-25%opatientswho
smokedhaddicultyadjusting
totherule,andsomepatients
experiencedmajordisruptionin
theirtx.
MDD-RSshadhigherrateso
abstinenceinCBTcompared
w/HE,evenwhenthe
contributionomoodandtheinteractionbetweenmoodand
anMDDxtxvariablewere
includedinthemodel.
Volume # /
Issue #
JoClinical
Psychiatry,
56(8)
Biological
Psychiatry,
52(1)
AmericanJ
oPsychiatry,
157(11)
Addictive
Behaviors,
22(6)
Clinical
Pharmacology
&Therapeutics,
54(6)
Hospital&
Community,
42(4)
JConsultClin
Psychol,72(4)
L I T E R A T U R E R E V I E W | 3 6
8/3/2019 Quit MHToolkit
50/55
Yr of
Pub
1994
1998
1996
2005
Author
Hall,S.M.,
Reus,V.I.,
MunozR.F.,
etal
Hall,S.M.,
Reus,V.I.,
MunozR.F.,
etal
Hall,S.M.,
Reus,V.I.,MunozR.F.,
etal
Haug,N.A,
Hall,S.M.
Prochaska,J.J.
etal.
Article Name
Cognitive-behavioral
interventionincreases
abstinenceratesor
depressive-history
smokers
NortriptylineandCBT
inthetreatmento
cigarettesmoking
Moodmanagement
andnicotineguminsmokingtreatment:
Athera