Prepare the smoking cessation in severe mental illness: Early diagnosis and prevention opportunities

Dear Editor,

Populations that suffer severe mental disorder (SMD) face high early mortality rates. The evidence is clear: these patients have a life expectancy up to 20 years shorter and the gap between them and the general population is growing larger.¹ These figures are the result of the interaction of various factors: those characteristic of SMD itself, associated health behaviours, factors stemming from the healthcare system and related social determinants. Even so, tobacco use is the main preventable mortality factor, and 50% of the patients with SMD who cannot manage to stop smoking will die from tobacco-related causes.²

Together with cardiovascular diseases, respiratory processes—specifically, chronic obstructive pulmonary disease (COPD) and pneumonia—are the main causes of mortality in patients with schizophrenia or bipolar disorder (BD).³ In spite of this, there are few studies about the onset, severity and evolution of lung damage in these patients.⁴ There are currently no clinical recommendations for early diagnosis in a population that, because of a use involving higher risk (earlier start, greater dependence levels, more intense smoking) and its demonstrated impact on mortality rates, could benefit from this early diagnosis.

Developing strategies to encourage patients to enter treatment is also a high priority,⁵ given that nicotine dependency can be treated safely and effectively.⁶ The efficacy of multicomponent treatment programmes has been demonstrated in this population, and such programmes emphasise the importance of the preparation phase before active treatment.^7,8 To optimise motivation, it is essential to focus on certain aspects: the intensity of the intervention, the individualisation of the message and the possibility of acting on factors such as the balance between the benefits and risks of continuing to smoke. The patient with SMD usually has a poorer perception of the health risks associated with smoking and, consequently, thinks less about health benefits as a reason for making an attempt to stop.⁹ Access to information on the individual tobacco-related health risks and the possibilities of preventing them can therefore represent an opportunity.

Mobile technology makes it possible to transmit health information and build motivation at any time and in any place. In treating tobacco use in the general population, even the most basic tools, such as text messages (SMS), have been extremely successful. In spite of the growing evidence as to their potential and safety in the treatment of patients with psychotic disorders, their possibilities are still unknown to a great extent in tackling tobacco use in this population.¹⁰

Our group is currently developing a randomised multicentre study with a year's follow-up on a sample of patients with BD and schizophrenia to establish the efficacy of a motivational intervention that offers individualised information of tobacco-related risk and the options of prevention. The level of undiagnosed lung damage—the calculation of pulmonary age and COPD presence and staging—is determined through spirometry. The intervention also explores the intensification using repeated motivational messages via mobile SMS technology.

Neurocognitive functioning will govern the reception of the information and the use that the patient might make of it. In schizophrenia and BD, deficits in several attentional functions, executive function and working memory that are essential for maintaining goal-oriented behaviour. Our design, in which these variables are controlled, should also help to ascertain their influence on motivational tools based on health information.

In short, the problem of tobacco use in this population needs new strategies that are effective in creating attempts to stop smoking and whose final goal is smoking cessation. A prevention-based intervention model is feasible and can find its ideal setting in community attention to mental health. A multidisciplinary team, one that knowledgeable about patients with SMD and their health needs, can offer a new option for approaching the tobacco-use problem by providing early diagnosis and building motivation.

Conflict of interests

Vicente Balanzá-Martínez has received grants and has served as a consultant, assessor or continuing medical education (CME) speaker in the last 5 years for the following organisations: Angelini Spain, Angelini Portugal, AstraZeneca, Bristol-Myers-Squibb, Ferrer, Janssen, Juste, Lundbeck, Nutrición Médica and Otsuka. Luis Gutiérrez-Rojas has been a speaker for and a member of the advisory councils for Bristol-Myers Squibb, Janssen-Cilag, Astra-Zeneca, Rovi, Lundbeck, Otsuka, GSK and Pfizer. María Paz Garcia-Portilla has been a consultant for Alianza Otsuka-Lundbeck, CIBERSAM, the European Union (7th Framework Programme), Hoffman La Roche, Instituto de Salud Carlos III, Janssen-Cilag, Lilly, Lundbeck, Otsuka, Pfizer, Servier, Roche and Rovi. All the remaining researchers have no financial-biomedical interests or possible conflicts of interest to declare.