Smoking cessation programs for persons with schizophrenia: An urgent unmet need

It is well-known that persons with schizophrenia are almost twice more likely to smoke than people in the general population, with worldwide prevalence rates of around 60%,¹ even in first episode psychosis.² In Spain the reported tobacco use rate in patients with schizophrenia is 54.4%,³ almost double that of the Spanish general population (26.4%).⁴ In addition, their smoking pattern is more pernicious and characterized by habit commencement about 5 years on average prior to illness onset,⁵ use of a greater number of cigarettes per day,^5,6 higher plasma nicotine levels^7,8 and more nicotine-dependence than general population.^9–11

Tobacco impact on the health of persons with schizophrenia

The high prevalence and specificity of the smoking pattern, which are attributed to several biological^12–14 and psychosocial^15,16 factors, play an important role in the high rates of medical morbidity and mortality found in this particular population,^3,15,17 with cardiovascular disease being the major contributor to excess death.^18,19 Furthermore, tobacco has recently been identified as a predictor of natural mortality in schizophrenia.²⁰

In addition to its negative impact on physical health, tobacco use in patients with schizophrenia has been associated with more excitement and agitation symptoms,^21,22 greater severity of global psychopathology as measured by the Clinical General Impression (CGI) scale,³ and positive psychotic symptoms,^3,23 although the effect size was small.³ Moreover, it is necessary to point out that tobacco smoking was found to be associated with higher rates of suicidal behaviours in patients with schizophrenia.²⁴ Quite the opposite, beneficial effects of tobacco on patients’ mental health have also been reported for negative symptoms.^23,25 Eventually, the pro-cognitive (attention, spatial working memory and sensory gating) effects claimed in different studies,^26,27 have been recently questioned by Núñez et al.,²⁸ so further research in this area is needed.²⁹ In either case, we believe that the potential beneficial effects of tobacco use do not warrant the maintenance of the smoking habit, as tobacco is associated with more than 4000 toxins including more than 60 carcinogens,³⁰ and, if proven necessary, nicotine can be more safely delivered through approved drugs.

Smoking cessation treatments: effective and safe

Bucking the downward trend in smoking incidence observed in the general population, despite awareness-raising campaigns to quit the habit, people with mental disorders continue to smoke at the same rate. However, in the last years, there is growing evidence on the efficacy, safety and tolerability of available pharmacological treatments for smoking cessation in persons with schizophrenia.

Several meta-analysis and reviews^31–35 as well as double-blind and pragmatic studies^36–42 have demonstrated that, in stabilized patients, available pharmacological treatments are effective and well-tolerated, being varenicline the drug with a greater body of evidence. Furthermore, recent reviews demonstrate that psychiatrists’ concerns about psychopathological exacerbations induced by these prescription medicines seemed to be unjustified.^{32,35,38–40,43,44} Moreover, data on the beneficial cognitive effects of varenicline have been reported in persons with schizophrenia.^45,46 However, Smith et al.⁴² using the MATRICS did not found this influence, so further studies are needed in order to clearly determine this effect.

Concerning safety, the overwhelming data from the EAGLES study in the subgroup of persons with mental disorders³⁹ led the EMA⁴⁷ to lift the warning on possible suicidal risk for varenicline. As a matter of fact, they stated that this medicine does not have dangerous psychiatric adverse effects both in the general population and in persons with mental disorders. The FDA is awaiting final approval for an amendment to its warning in the same direction.

Barriers that prevent tobacco cessation among people with schizophrenia

In spite of all the evidence above described, a study described that only a third of clinicians give guidance about smoking cessation⁴⁸ to their patients with bipolar disorder, although the emerging findings show that people with severe mental disorders are motivated to quit.^49,50 Among the possible hurdles we would like to highlight: (1) the lack of resources, both by the health system (lack of specific programmes for this patients) and by the patients (unfeasibility to afford the cost of the medicines); (2) the negligence and old prejudices of psychiatrists; and (3) the medical stigma that suffer such patients. Thus, the main challenge consists of how to proceed to motivate health managers and psychiatrists to follow ethic norms and leave behind long-standing biases,⁵¹ in order to implement and rely upon specific resources for helping patients to quit smoking. In this sense, guidance for psychiatrists on strategies for tobacco use cessation in people with mental illness has been published^52–56 as a tool to encourage eradication of the therapeutic nihilism in this area.

In conclusion, given the aforementioned factors, we believe we are now ready to bend the curve of this hidden public health problem and provide a boost against tobacco cessation, and the current therapeutic nihilism that prevails in Psychiatry. Thereby, we shall be able to prevent the onset/worsening of cardiovascular diseases, and to improve the general health and life expectancy of our patients with schizophrenia.