Psychiatric Patients And Tobacco Smoking

Psychiatric Patients And Tobacco Smoking

Patients with anxiety disorders, attention-deficit disorder, mood disorders, substance use disorders, and other mental problems have a 2-3 times higher prevalence of tobacco use and tobacco use disorder (TUD).

Compared to people who have never smoked or who are ex-smokers, current smokers have these mental illnesses two to three times more frequently.

Possible Reasons For This Association Are The Following

• Genetic predispositions to smoking and mental health issues
• Subjective enhancement aided by nicotine. Tobacco users with schizophrenia benefit from its capacity to sharpen their focus and lessen their extreme sensitivity to external sensory inputs.
• Nicotine is used as a self-medication by depressed patients to treat psychomotor retardation, sleep disorders, and specific depressive symptoms.
• Another factor contributing to this relationship is boredom.
• Substance abuse, attention deficit disorder, and depression symptoms all predict the chance of beginning to smoke, the likelihood of developing a dependence, and the potential of being unable to quit.

Also Read: Substance Related Addictive Disorders

Psychiatric Patients And Tobacco Smoking

Smokers among psychiatric outpatients: 50% of all outpatients, 70% of those with bipolar disorder, and 90% of those with schizophrenia.  Smoking is a habit for 70% of patients with drug use disorders.

Treatment Of Tobacco Use Disorder

 Every patient has to be evaluated for:

• Current smoking status
• Attempt to evaluate tobacco usage, both past and present;
• Type of tobacco use;
• Frequency of tobacco use and evaluation for the diagnostic criteria
• The 5 A's model, which consists of the following: ask, advise, assess, help, and set up follow-up.  It's important to enquire about both previous and present tobacco use.
• Provide personalized advice to stop using tobacco products. (For example, "One of the most important things you can do is to quit smoking.")
• The cumulative effect of advice is effective even though it may not happen right away.

Health concerns, the effects of smoking on others, and social pressure are common motivators to quit. Common barriers to quitting include withdrawal symptoms, fear of failure, and fear of gaining weight. Assess the desire to quit, which includes assessing the level of motivation to stop smoking and trying to increase the motivation based on the money spent, job opportunities, and the effect of tobacco smoking.
Help the patients decide what to do. Help set up a quit date and have a discussion about the plan of action.

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How To Set A Quit Date?

Suggest a meaningful occasion (birthdays, anniversaries, etc.) Encourage stopping with a friend or spouse, etc.; Allow to plan and tell others about it to help write up a list of reasons to quit; and preferably within, but not limited to, two weeks.  Set up the follow-up counselling and include TUD in the plan to help with cessation and prevent relapse.

Treatment Modalities

There are two treatment modalities. The preferred one is psychosocial interventions, and the other is pharmacotherapy.

Psychosocial Interventions

 Involves feedback that is more significant, such as co-meter scores, the annual cost of cigarettes for them, the severity of any current health issues, and the impact on family and significant others. Healthy living education and programs might boost their motivation.

A lot of people employ behavior therapy, which consists of:  Relapse prevention (practice and preparation for such situations): It employs the four To prevent relapsing, avoid, change, substitutes, and activities.
  Coping techniques employ the five Ds: delaying the urge, diverting your attention, sipping water, taking deep breaths, and talking to someone about how you're feeling to lessen the urge.

Hospitalization, acupuncture, hypnosis, and aversive therapy are among the other therapies;  Mindfulness-based intervention lowers stress;  Stimulus control involves removing triggers for the smoking environment.  Clinic-run smoking cessation groups and online websites/apps can also be helpful.

Hypnosis

 Physicians can also employ posthypnotic ideas that taste bad or make them queasy.  Hypnotists offer benefits of quitting smoking thoughts, which patients integrate into their cognitive system.

Aversive Therapy

 Smokers habitually and quickly smoke themselves sick, associating smoking with unpleasant (as opposed to pleasant) feelings.  Seems to be functional.

Also Read: Communication Disorders In Child Psychiatry

Guidelines For Psychosocial Interventions

• Clinical practice guidelines (CPG) for the treatment of tobacco use disorders are the first set of recommendations. (The 2014 SUD specialized section of IPS)
• The Mayo Clinic NDC (Clinical Practice Guideline on treating tobacco use and dependence, 2008, revised 2015) is the second recommendation for medication-assisted tobacco dependency treatment.
• CPG employs the five as a management role model
• Counselling is the most basic type of tobacco cessation intervention; it improves CPG's drive to stop and their capacity to resist the urge to smoke.

Brief intervention is also helpful in helping people quit smoking. Minimal intervention is also beneficial. Psychiatric intensive counselling is also crucial.

Five fundamental motivational principles, which are included in motivational interviewing, may be helpful. These are:
Developing discrepancy, avoiding debate, rolling with resistance, expressing empathy, supporting self-efficacy, relapse prevention.

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Components Of Relapse Prevention And Intensive Psychosocial Counselling

 Using contemporary technology ensures privacy and is practical, such as telephone-based interventions.  Online counselling is also becoming more popular.

Key Recommendations: Counselling

 Counselling works regardless of its type, frequency, or severity. Even a quick intervention, a few minutes or less, can have a positive impact.  Proactive telephone counselling is preferable to standard quitlines.

 A doctor's brief recommendation to quit increases the likelihood of quitting, Customized online counselling may be beneficial. Behavioral assistance and medication together promote smoking cessation.

Also Read: Human Aggression: A Comprehensive Approach 

Nicotine replacement therapy (NRTs), which includes nicotine gum, lozenges, patches, inhalers, and sprays, is one of the many medications that the FDA has approved. Inhalers and sprays are only accessible with a prescription; lozenges and patches are available over-the-counter.

They are typically regarded as the initial course of treatment. Varenicline and bupropion, two non-nicotine treatments, are approved; These drugs all double the fast rate.  Nasal sprays have fewer negative effects than other medications. Varenicline is more effective than other therapies.

Factors For Choosing Medications

Combining drugs has been demonstrated to be more effective; examples include using a patch with another NRT or varenicline monotherapy.  New FDA recommendations on NRTs encourage the use of several medications and permit their use alongside smoking while reducing risk.

Nicotine Replacement Therapies (NRTS)

Because NRTs lessen nicotine withdrawal, they are incredibly effective.
The majority of NRTs employ a brief maintenance period (6–12 weeks), without the immediate reinforcing impact of rapidly absorbed nicotine in tobacco smoke;  They are frequently followed by a progressive decrease period (6–24 weeks).

In certain situations, using NRTs for longer periods of time may be required.  Patients with cardiovascular disorders, particularly those with unstable angina, severe arrhythmia, and less than two weeks since myectomy, should use NRTs with caution.  They reduce the intake of acidic drinks. 15 minutes before and during use is when it should be consumed.

Nicotine Gums

Gums can be used on their own or in combination. They are taken hourly during the first few hours of quitting. Gum with 2 mg is advised for less than 25 smokes a day. For heavier users, 4 mg is recommended.
Smokers take one to two pieces per hour, up to a daily maximum of twenty-four pieces. PROS: – Easy and flexible dosing; quicker nicotine delivery than patches; CONS: – May not be suitable for individuals with temporomandibular joint (TMJ syndrome) or dental issues.

 To help maximize nicotine absorption for 30 minutes and reduce transfer to the stomach (which can irritate the GI tract), patients should chew for a few crunches until a peppery/tingly flavor emerges. They should then park between cheek and gum until the tingle goes away.

 Patient education regarding proper usage is very important.
2% of users use the gum for more than a year. 20% of users stop using it for longer periods of time. Nicotine gums have benefits and drawbacks.

Nicotine Lozenge

Nicotine lozenges have the highest level of nicotine of any NRT; users must suck the tablet until it dissolves, not chew it; they provide the highest level of nicotine of any NRT; patients who smoke their first cigarette within 30 minutes of waking up are prescribed a 4 mg lozenge; others are prescribed a 2 mg lozenge; side effects of lozenges include hiccups, nausea, heartburn, headaches, and insomnia;

In high-risk situations, nicotine gum and lozenges rescue of immediate withdrawal experience; advantages are similar to gums and can be used by patients with dental issues; disadvantages include no role in craving

Nicotine Patches

It provides long-term nicotine administration. It is applied every day in the morning to a clean, hairless area. It can be placed anywhere on the upper body, including the arms and back. It rotates and a fresh patch needs to be applied each time. It is available in strengths of 21 mg, 14 mg, and 7 mg.

The benefits of this product include achieving the required level of replacement, being easy to use, only requiring a daily application, and having fewer side effects. The drawbacks include having less adjustable dosing, a slower commencement of delivery, and the possibility of mild skin rashes and irritation.

It raises the quit rate by an additional 50% • Higher-risk scenarios are treated with gums and patches. Generally, it is stopped after six to twelve weeks. Skin responses are one of the side effects, but they can be reduced with creams and by switching up the patch sites. CPG, 2014: Dosage, administration, and side effects of nicotine patches

Advantages

It is easy to use, as once per day use. It provides a steady nicotine level.

Disadvantages

Slow release of nicotine: The user cannot alter nicotine level in case of a breakthrough craving

Nicotine Inhaler

It is meant to be absorbed through the oral mucosa.

PROS:  Its variable dosing. Its hand-to-mouth behavior mimics that of smoking .  Less adverse effects

CONS: It may irritate the tongue or throat . Regular use during the day is necessary to acquire appropriate nicotine levels. Its rapid delivery of nicotine and control over its delivery are its advantages. Its drawbacks include frequent puffing and device visibility when in use. The Mayo Clinic states that the recommended dosage for monotherapy is at least 6 cartridges per day and as many as 16 cartridges per day. Taper as tolerated.

Nicotine Spray

It can induce rhinitis, watery eyes, and coughing. It has the fastest absorption rate of NRT medications. It has the largest potential for dependency.

PROS:  Adaptable dosage - May be used to relieve stress or cravings for smoking.

Quickest nicotine delivery among NRT products currently on the marketCONS:  Common nose and throat infections normally go away in a week .  Regular use during the day is needed to get enough nicotine . Rare nose bleedsDosing as monotherapy, according to the Mayo Clinic, entails one spray in each nostril (1-2 times per hour); most users begin with an average of 14–15 doses per day; and tapers as tolerated.

CPG states that:  Combined NRT produces sustained nicotine doses with quick adjustments for urgent needs .  More effective than monotherapy; nonetheless, there is a larger risk of toxicity and higher expense.  There are eight licensed NRT products in use in the UK:

Patches applied topically.  S/L pills; mouth spray; nasal spray; lozenges; inhalator; oral stress

Pharmacotherapy

A partial agonist called vanenicline is used to ease withdrawal and cravings.  By preventing the activation of nicotine, it lessens its reinforcing effects.  In its current form, it stabilizes the channel.
The most frequent side effects include nausea, vomiting, constipation, headaches, and odd dreams. It is normally started one week prior to the quit date and the dosage is gradually raised. It reduces withdrawal symptoms by triggering at least some neuromodulation.

PROS: Generally well accepted, available in pill form, simple to use, and no known drug interactions
CONS: Common adverse effects include nausea, strange nightmares, and sleep disruptions.

Cardiovascular adverse events and neuropsychiatric symptoms, including as depression, agitation, and suicidal thoughts, are included in black box warnings. The medications should be taken with food; the doctor should keep an eye out for symptoms relating to the patients' cardiac and mental health. Take one milligram twice day for eleven weeks.

Another medication that lessens cravings and withdrawal symptoms is bupropion SR.  300 mg should be taken daily. Both smokers with and without depression have twice as many quit attempts.  102 weeks prior to the stop date, it can be started;

Typical side effects include headaches, convulsions, dry mouth, and insomnia.  Bupropion's black box warning lists neuropsychiatric adverse effects.

The Mayo Clinic advises separating doses by at least eight hours. One week ahead to the intended stop date, begin taking the medication. It is recommended to take 150 mg once daily for three days, followed by 150 mg twice daily for four days. After that, quit smoking on TQD.

CONS:  May interact negatively with MAO inhibitors and be contraindicated with certain medical conditions;  Another drug, nortriptyline, looks to be helpful for quitting smoking.

PROS:  Easy to use, in pill form, less side effects, and may be used in tandem with NRT. It starts 10–28 days before the planned stop date and is titrated up from a starting dose of 10–25 mg/l to 75–100 mg/day.

Nortriptyline and clonidine are two examples of second-line pharmacotherapies. If one line is ineffective, any can be taken into consideration.  Pharmacotherapy and psychotic treatments together improve efficacy and raise the rate of cessation.

Smokeless Tobacco

Nicotine patches and lozenges are taken into consideration; nicotine inhalers and nasal sprays are not advised in the case of smokeless tobacco; and non-nicotine pharmacotherapy such as bupropion and varenicline may be useful.

Deterrent Therapy

 Sulfurides in tobacco smoke react with silver acetate to form sulfide salts, which are incredibly tasteless.

Treatment Of TUD For Psychiatric Patients

 Because they smoke more effectively and consume more nicotine, psychiatric patients with TUD experience more withdrawal symptoms and have a harder time quitting.

Treatment Of TUD And Pregnancy

The use of drugs to help quit smoking during pregnancy is controversial because it can have an impact on both the mother and the unborn child.

Prevention

Has been a strategy of progressive lowering for people who are less driven.  Using this tactic frequently results in compensatory smoking. The possible advantages of harm reduction are minimized.

Taxation on tobacco products, bans on smoking, media counter-advertising, bans on sales to minors, warning labels on cigarette packaging, and criticism of the tobacco business as immoral were the main topics of several legislation.India is the world's second-largest producer of tobacco, after China. The national tobacco control program seeks to raise public knowledge of the negative consequences of tobacco use, minimize tobacco production and supply, and guarantee successful implementation.

Tobacco Cessation Clinics (TCC), a joint program between WHO and MOHFW, was established. Later on, it was renamed Tobacco Cessation Centers, and its responsibilities were broadened to include creating awareness about quitting smoking and providing instruction on quitting.

 May 31, 2005, was designated as World No Tobacco Day; Chandigarh became the first city to ban tobacco in 2007;  Sikkim became the first state to ban tobacco in 2010;

Hope you found this blog helpful for your Psychiatric Theory and Specialities Preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.