The relevance of nicotine dependence to psychiatric syndromes

Nicotine is a psychoactive drug, which releases a number of brain neurotransmitters and has both stimulatory and calming effects (Henningfield et al, 1995). In the short term, noradrenaline and dopamine release enhances pleasure and reduces tension and anxiety. Noradrenaline and acetylcholine release gives some improvement in cognitive performance. Noradrenaline can facilitate nicotine’s ability to screen out irrelevant stimuli, thereby increasing concentration. The release of dopamine, norepinephrine and serotonin leads to a reduction in hunger.

The criteria for DSM-IV diagnosis of nicotine dependence are, (i) daily use of nicotine for at least several weeks, (ii) abrupt cessation or reduction leading to withdrawal symptoms, and (iii) significant distress or functional impairment. Those with schizophrenia, depression, bulimia, alcohol and drug dependence (Glassman, 1993) tend to have higher rates of nicotine dependence than the general community and there are complex interactions between nicotine, other components of tobacco and the course of psychiatric disorders. Nicotine has been shown to have positive effects on the course of ulcerative colitis and ADHD (Henningfield et al, 1995). There is also an effect causing later onset of Parkinson’s Disease. These findings highlight the importance of separating out the effects of nicotine from smoking and it may well be that there are some therapeutic effects of nicotine that will be more evident over time.

There have been recent sets of guidelines for the management of nicotine dependence (American Psychiatric Association Practice Guidelines, 1996; Agency for Health Care Policy and Research Smoking Cessation Guidelines, 1996). Some of the recommendations emanating from these include: routine enquiry of smoking status and previous attempts to stop, routine use of the diagnosis of nicotine dependence and frequent advice to stop and assessment of readiness to stop. They state that the outcome is better if smokers wishing to quit are in a "state of readiness".

These guidelines include strategies for managing nicotine withdrawals, provision of ongoing support and the APA guidelines ideal more specifically with the particular problems for people with mental illness, some of which will now be discussed. The AHCPR Smoking Cessation Guidelines the severity, the availability of effective interventions and the lack of consistent intervention by clinicians.

• Smoking and pregnancy

There have been reports of the effects of maternal smoking on the foetus. These include increased rates of low birth weight babies, greater infant mortality, higher incidence of Sudden Infant Death Syndrome, higher rates of asthma, nicotine dependence in their offspring, particularly for girls and higher rates of Attention Deficit Hyperactive Disorder, more behavioural problems and modest impairments in cognitive development in their children. The relationship between smoking and pregnancy deserves special mention. Women who smoke regularly are more likely to become depressed during pregnancy and depressed, pregnant women are less motivated to stop smoking and have greater difficulty doing so. Pregnant teenagers are more likely to be smokers, often with less years of formal education, possibly not wishing to be pregnant or in the midst of personal turmoil, all leading to decreased motivation for smoking cessation and constitute a particularly vulnerable group (Wilhelm, 1997).

• Smoking and depression

While smoking can lead to a temporary mood enhancement (through action of nicotine), daily smoking can lead to an increase in incidence of depression (Breslau et al, 1998). This may be related to MAOB depletion (by a non-nicotine component of tobacco) and there has been discussion about a common gene for nicotine dependence and depression. Smokers with a previous depressive history have a 20-30% relapse in depression on smoking cessation (Covey et al, 1997), however, antidepressants do have a role, and tricyclics (TCAs), SSRIs and moclobemide have all been shown to be useful. Sedating TCAs (such as doxepin) have also been shown to be useful in ameliorating withdrawal effects (American Psychiatric Association Practice Guidelines, 1996).

Recent developments in neuroimaging and neurocognitive testing have provided evidence of brain pathology as an important factor leading to a late onset of major depression. The ‘vascular depression’ hypothesis (Alexopoulos et al, 1997) has important implications for late-onset depression in terms of prevention of cerebrovascular disease in which smoking is a key risk factor here. This will become increasingly important as populations age and the morbidity profile changes towards more chronic illness.

Young people are particularly vulnerable to dysphoria due to the vicissitudes of adolescence, which in combination with peer pressure towards risk-taking and their wish to disregard "sensible adult values" leads to an onset of smoking (Patton, 1996). Young people with a prior history of early conduct problems are particularly vulnerable. For young women, the use of nicotine as an appetite suppressant is becoming increasingly important in relation to eating disorders. The dopamine mediated addiction centre is shared by nicotine, cocaine, amphetamines and heroin. Nicotine is generally the first of these drugs to be used and acts as a "gateway drug", facilitating addiction to other substances (Stolerman & Jarvis, 1995). There is decreasing acceptance of smoking in public places and pressure for provision of smoke free venues, making smoking a vehicle for special protest At the same time the introduction of smoke free devices for nicotine delivery may lead to a new status for nicotine as a ‘smart drug’ for young people, more akin to amphetamines or ecstasy.

• Smoking and schizophrenia

People with chronic schizophrenia have extremely high rates of tobacco consumption (up to 90% with chronic schizophrenia smoke). Nicotine affects an auditory gating mechanism, temporarily alleviating the experience of auditory hallucinations in those with schizophrenia, but the reverse in normal controls (Adler et al, 1993). There is a greater than 20% risk of schizophrenic relapse on smoking cessation (Glassman, 1993). Nicotine is metabolised by the cytochrome P450 pathways and competes with various neuroleptic medications, including phenothiazines, olanzepine and clozapine (Henningfield et al, 1995). Thus people with schizophrenia require increased medication because of increased metabolism which also leads to increased side effects, including dysphoria, which they may seek to counteract by increasing their smoking. However, stabilisation on clozapine may lead to dramatic reduction in cigarette consumption and the urge to smoke. Smokers also have higher rates of akathisia and tardive dyskynesia (APA Practice Guidelines, 1996). While suicide is the greatest contributor to early mortality in schizophrenia, smoking related diseases come second. People with schizophrenia have high rates of lung disease, but lower than expected rates of lung cancer, which may be related to neuroleptic-induced prolactin release (ref).

There are a number of social issues that arise in relation to smoking arise that are particularly relevant for those with chronic schizophrenia. These people are likely to be taking long-term medication (which can be sedating and induce weight gain), they may be bored and have poor social resources. Cigarettes are a form of social currency, as social ‘ice breakers and 'punctuation marks' through the day. They can also provide a focus for expression of frustration and irritability.

At meetings attended by the author, where this material has been discussed, there is considerable concern about the desirability of ‘taking away the only pleasure’ available to socially disenfranchised people who have little in their lives to aspire to. An alternative view is that it is somewhat patronising to assume that this is the only pleasure left and the economic reality is that heavy smokers have little money left with which to pursue other interests if they spend up to half their income on cigarettes.

There is now an embargo on smoking in public hospital facilities with psychiatric units being most affected because of the high rates of smoking inpatients. The trend towards increasing recourse to litigation in USA by current and previous smokers who have allegedly suffered from smoking-related effects on their health and from non-smokers has yet to occur in Australia. Nonsmokers are becoming more assertive in complaining about the smoking habits of fellow-patients. There is also the possibility of litigation by patients who commence their smoking in hospital or find themselves smoking more after admission.

On admission to hospital, patients are often highly distressed and angry about their circumstances. They are often surrounded by a high concentration of smokers (both patients and staff). The amount of social support and understanding from family, friends, work and mental health professionals is clearly important to discourage increased nicotine consumption or encourage cessation. Staff attitudes to smoking are very important and the APA guidelines (1996) have noted this is one of the "barriers to the provision of smoking cessation care to inpatients". There have been recent reports of locked psychiatric ward, which are totally smoke-free (APA Practice Guidelines, 1996). Patients are given access to nicotine patches and gum, as well as psychological support and counselling. Considerable planning is required but the actual experience has been better than expected. Despite the concerns of staff, patients did not become angry or violent, and critical incidents did not increase.

In aftercare facilities, the high rates of smoking are a problem for a recent quitter. At home with family, those who smoke can often feel isolated from others and heavy smoking may constitute a reason for the family not wishing the smoker live at home. It is easier for a recent quitter to continue as a non-smoker in a supportive non-smoking environment and this needs careful consideration when accommodation needs are being examined (APA Practice Guidelines, 1996).

There are also issues in the duty of care towards vulnerable people who may start or increase their smoking during a first admission during an early stage of a psychiatric disorder without being aware of the consequences. There are differing issues of duty of care to non-smokers and, at the other end of the spectrum, towards very heavy smokers with severe psychiatric disorders.

• Implications for staffing of mental health services

These are some of the questions raised during discussion of the implications of smoking for clinical psychiatry:

1. Are the health services prepared to put any more energy and money into adopting a health promotion approach towards lifestyle issues? Who should provide (and pay for) the extra services that may be required?
2. What are the effects of admitting people to accommodation in psychiatric units where smoking is "the norm"?
3. Are we doing enough to consider, encourage and support nonsmoking patients?
4. There are differences in attitude between staff who are nonsmokers and previous smokers. The latter group is likely to be more sympathetic to those who are quitting. Do non-smoking staff members require specific training in this respect?
5. Is it appropriate for smoking staff to be delivering health promotion messages at all when they are clearly not attending to the available evidence concerning the effects of smoking on health?
6. Based on growing knowledge on the effects of passive smoking, what consideration should be given to the smoking environment in discharge planning? Should there be provision for smoke-free supported housing?
7. If people with chronic mental illness and poor social skills do decrease or cease cigarette consumption, are they offered interesting, effective alternatives?
8. Many smoking patients state that they would rather "cut down" than stop, but "cutting down" may not be a viable option The dynamics of nicotine dependence are such that reduction in cigarette intake to around 5 cigarettes per day allows time for neurotransmitter stores to be replenished and leads to an increase in addiction (Henningfield et al, 1995.
9. Is there sufficient promotion of interactions between nicotine and medications?
10. Do we know enough about pharmacological interventions (in particular, antidepressants) in the management of smoking cessation?

• Recommendations

1. We need ongoing discussion between the medical profession, the fundholders and general public on the merits and cost benefits of providing health promotion strategies and smoking reduction and cessation strategies for those with established psychiatric disorders.
2. Health professionals should be critically aware of the messages they are conveying in terms of smoking, particularly if they are themselves smokers. This issue is likely to increase in importance with the growing concern about the health risks of smoking and greater appreciation of nicotine dependence.
3. For some patients with long histories of psychiatric illness and nicotine dependence, nicotine replacement is a more realistic option, in a similar manner to methadone replacement for opiate dependence. More debate is required concerning the effectiveness of such treatment in the long term, and if effective, who pays.
4. Psychiatric history taking should detail smoking history, including assessment of smoking status of patient and others in patient’s household, the relationship with psychiatric illness, previous attempts to quit and potential for relapse of psychiatric disorder at those times, and assessment of current readiness to stop (in line with APA Practice Guidelines).
5. There is a need to distinguish between smoking and nicotine dependence. The DSM-IV diagnosis of nicotine dependence should be used routinely and the information conveyed to those affected. Self-report instruments of nicotine dependence should be available.
6. The outcome for smoking cessation is better if the smoker is in state of readiness. Psychiatrists should be familiar with techniques to assess ‘readiness to quit’ can be part of the routine assessment (Rohren et al, 1994).
7. More active (and informed) interventions are required to encourage nonsmokers at the early stage of their illness to maintain a nonsmoking lifestyle, or to maintain lower levels of consumption.
8. Blood levels of antipsychotics can increase significantly following nicotine withdrawal and medication review is required after smoking cessation. Knowledge of decreased medication needs and fewer motor side effects after smoking cessation can be used as a strong motivating factor.
9. More research into effective strategies for specific subgroups is required. These include groups include young people with early psychosis, girls watching their weight, single pregnant women, migrant groups from countries with different attitudes to smoking (e.g. China, where smoking has been encouraged until recently), long-term smokers with serious psychiatric disorders.

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