Nicotine dependence in psychiatric disorders.

Nicotine dependence is among the most common comorbid disorders in patients with psychiatric disorders. Evidence-based pharmacologic and non-pharmacologic smoking cessation programs (REPs) are also effective in patients with psychiatric disorders. Meta-analyses show that nicotine dependence treatment does not increase psychiatric disorders – the opposite is observed! Successful nicotine dependence treatment reduces the risk of further physical ailments and psychological disorders. Smoking cessation programs should become an integral part of comprehensive psychiatric treatment.

People with psychiatric disorders have massively increased rates of nicotine dependence compared to the normal population [1,2]. This is especially true for patients with schizophrenia [3], depression [4], or bipolar disorder [5]. Compared with the normal population, nicotine dependence in psychiatric patients is more persistent, more frequent, and, for example, begins almost five years before the first psychosis in patients with schizophrenia [6]. Patients with psychiatric disorders and concurrent nicotine dependence have lower life expectancy compared with patients with psychiatric disorders without concurrent nicotine dependence; on the one hand, nicotine dependence leads to increased cardiovascular disease [7], lung disease, cancer [8], and food craving (impulsive eating and drinking behavior) [9]; on the other hand, nicotine dependence is a statistical predictor of increased suicidality in patients with schizophrenia [10] and other psychiatric disorders [11]. The best predictor of nicotine dependence and low response to smoking cessation programs (REPs) is nicotine intake within the first 30 minutes of awakening [12].

Physiologically, nicotine increases dopamine levels in the nucleus accumbens by acting on alpha4beta2 nicotinic acetylcholine (nACh) receptors in the mesolimbic reward center [13], which promote dopamine release.

A hypothesized interaction model [14] to explain increased nicotine dependence in psychiatric disorders describes the following factors that trigger and maintain nicotine dependence: (a) shared genetic predispositions between nicotine dependence and psychiatric disorder; (b) psychosocial stressors; c) social environment in which nicotine use is considered common, and (d) the temporary reduction of anxiety and depression states. This reduction is understood in learning theory in the context of operant conditioning as a reinforcer to repeat a behavior pattern. Nicotine dependence can thus be understood as dysfunctional self-medication within a specific social context with an additional possible genetic vulnerability: In the short term, relief of anxiety, depression, and stress perception takes place; in the long term, nicotine dependence leads to increased levels of anxiety, depression, and stress.

People with psychiatric disorders also have a fundamental interest in treating nicotine dependence; thus, contemporary psychiatric treatment should offer smoking cessation programs (REPs) [15,16]. These REPs, moreover, are not significantly different from REPs for non-psychiatric individuals. Often cited barriers to smoking cessation include. a) Too high target expectations (rapid nicotine abstinence in the shortest possible time), b) underestimated chances of success (“I’m not going to make it after all!”), c) lack of know-how of the patient (“How do I do this?”) and d) the practitioner (“What are the REPs and how do I apply them?”), (e) demonstrable misconceptions about the short- and long-term consequences of a REP in people with psychiatric disorders [17].

In their meta-analysis, Taylor et al. [18] showed that six weeks to twelve months after a successful REP, scores in depression, anxiety, and stress had decreased, and scores in mood and quality of life had improved. Nicotine abstinence therefore had a causal effect on the improved scores because no other interventions had taken place during the observation period and because there has been no description in the literature to date of systematic positive “life events” leading to lasting improvements in mood in a larger number of individuals during the same period. Taylor et al. [18] could not exclude that regular physical activity as a confounding variable would have led to mood improvements. However, this possibility seems very unlikely due to the now epidemic prevalence of physical inactivity [19].

A detailed motivational interview should be conducted prior to a pharmacological and non-pharmacological REP.
Zwar et al. [1,20,21] propose the 5A rule:

Ask (“Ask each patient if he/she wants to stop smoking”).
Advice (“Suggest a stop smoking”)
Assess (“Elicit the level of nicotine dependence and the level of motivation”).
Assist (“Help the patient make the decision to quit smoking”).
Arrange (“Organize smoking cessation and motivate the patient in persevering”).

Pharmacological treatments (see Mendelsohn [1] for a detailed description) include nicotine replacement therapies (NETs), varenicline (^Champix®; ^Chanlix®), bupropion (^Wellbutrin®), and the combination of NETs and varenicline or bupropion: NETs + varenicline, for example, increase success rates threefold over placebo [22,23]. NETs should be started around two weeks before actual nicotine cessation, and close treatment monitoring is very important if additional psychotropic drugs are taken: Changes in effect should be quickly discussed by the patient with professionals in order to keep treatment adherence high and to make the REP stable and successful.

Non-pharmacological methods include Mindfulness-Based Stress Reduction (MBSR); the meta-analysis by Oikonomou et al. [24] describes that after four months of MBSR, the abstinence rate improved twofold to about 27% compared to treatment-as-usual. Insufficient data are yet available to assess the effect of regular physical activity alone as a REP [25]. However, “regular physical activity” should by now be part of the standard treatment program for patients with psychiatric disorders [26-31]. Regular physical activity has a mood-lifting and anxiolytic effect [32,33] and is excellent for counteracting possible weight gain after an REP [34].

Several vendors for all modern mobile phone devices offer apps with behavioral therapy-oriented REPs (Fig. 1).

In summary, people with psychiatric disorders have significantly increased nicotine dependence, nicotine dependence leads to other massive physical and psychological impairments, patients with mental disorders want to treat nicotine dependence, and REPs are an integral part of contemporary and comprehensive treatment.

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