Group Treatment for Smoking Cessation Among Persons With Schizophrenia

Although a great deal of information has been disseminated to the public concerning the health hazards of tobacco smoking, many heavy smokers are unable to stop. Compared with the general population, psychiatric patients, particularly those with a diagnosis of schizophrenia, have a higher prevalence of smoking (1). The rate for the general population is 30 percent, and rates range between 62 percent and 81 percent for people with schizophrenia (1,2,3).

This paper reviews current knowledge about smoking and schizophrenia and examines three programs for smoking cessation developed for use with this population.

Nicotine and schizophrenia

Some implications of nicotine use are specific to people with schizophrenia (4). First, nicotine has been shown to increase the release of dopamine in the nucleus acumbens and the prefrontal cortex (5,6,7). Glassman (8) suggested that the apathy and lack of motivation characteristic of negative symptoms is what one would expect with diminishing activity of the brain's reward system. He further suggested that nicotine's ability to augment dopamine release could be seen as a potential physiological antagonist to negative symptoms, which might be one of the underlying reasons for the high prevalence of smoking among individuals with schizophrenia.

Smoking may reduce blood levels of antipsychotic agents through a pharmacokinetic interaction (8,9,10,11). As a result, individuals with schizophrenia who smoke may require a higher daily dosage of neuroleptic (3,12,13). A relationship between increased tardive dyskinesia and smoking has been reported (14,15), which may be due to the higher doses of neuroleptics required by these patients (3).

An association between cigarette smoking and a reduction in the incidence of idiopathic Parkinson's disease has also been suggested (16). Because both idiopathic and neuroleptic-induced parkinsonism seem to share certain characteristics, it is possible that smoking may prevent or delay the occurrence or lessen the severity of neuroleptic-induced parkinsonism. Among persons with schizophrenia, significantly less neuroleptic-induced parkinsonism has been noted among smokers than among nonsmokers (12), but the finding is not consistent (14).

Smoking cessation for persons with schizophrenia

Resnick (17) has suggested that psychiatric patients are as likely as others to benefit from quitting smoking. In a recent Canadian study of 60 outpatients with schizophrenia, the majority were interested in attending a smoking cessation group and were intrinsically rather than extrinsically motivated; intrinsic motivation is seen as a good prognostic factor in smoking cessation (18). Results of that study were supported by a report of a survey conducted in Hamilton, Ontario, of 105 individuals with schizophrenia and focus groups with 28 subjects who had schizophrenia (19).

However, due to the cognitive, affective, and social deficits associated with schizophrenia, it is likely that existing programs may not be suitable for this population. Little evidence can be found in the literature that smoking cessation programs exist for or have been evaluated for effectiveness with a chronic psychiatric population. Breckenridge (20) reported on an individual smoking cessation program for psychiatric outpatients. Twenty-three patients with schizophrenia were referred, of whom eight (34 percent) succeeded in quitting smoking, and five (21.8 percent) were abstinent for at least one year. Ziedonis and colleagues (21,22) described a ten-week smoking cessation trial of psychosocial treatment in conjunction with nicotine replacement for 75 subjects, assigned to either once-a-week or twice-a-week sessions. Two types of once-a-week treatment were offered—supportive behavioral psychoeducation and motivational enhancement therapy. The twice-a-week treatment was motivational enhancement therapy. Both treatments yielded 15 percent abstinence rates at six months.

My colleagues and I recently completed a study in which 50 individuals with schizophrenia participated in one of five smoking cessation groups (23). These individuals had a long history of schizophrenia and had been heavy smokers for many years. They were keen to stop smoking, were intrinsically motivated, and generally showed good attendance. A significant number of individuals (42 percent) stopped smoking for at least four weeks. This number decreased to 16 percent three months after the group ended and to 12 percent at six months. However, this sample of quitters was relatively naive—30 had made no previous attempts at quitting. This finding is important, as people may need at least five attempts at quitting before they are successful (24). At the six-month follow-up, 34 of the 40 who were smoking again wanted to try to quit again. No increases in symptoms of schizophrenia were apparent among those who stopped smoking.

Treatment methods

Three separate group programs have been described in the literature to help individuals with schizophrenia stop smoking. In the study by Ziedonis and associates (21,22) the ten-session behavioral therapy component focused on relapse prevention strategies, including identifying personal triggers to smoke and developing coping strategies to manage those triggers. Typical triggers are environmental cues, specific times of the day, friends who smoke, and mood states. Motivational enhancement techniques were also used. Motivational enhancement therapy, which focuses on strengthening the client's motivation and commitment to change, is described by Miller and Rollnick (25) and in a manual for Project MATCH published by the National Institute on Alcohol Abuse and Alcoholism (26). The therapist adopts an empathic approach and elicits the patient's own self-motivational statements. An individualized plan for quitting that is acceptable to the client is developed (21,27).

In our recent study (23), my colleagues and I used a treatment based on the eight-session, seven-week group program "Freedom From Smoking" designed by the American Lung Association. The "Freedom From Smoking" program was modified to meet the needs of this particular population. The eight sessions followed the plan outlined below:

• Introduction to smoking cessation

• Building motivation and preparing to quit (how the habit developed, barriers to quitting, and reasons to quit)

• Developing a "quit plan" and learning techniques to quit (patches, fading techniques, the buddy system, and relaxation)

• Quit day (contracts and rewards, reinforcement of changes, coping with cravings, and reviewing strategies and techniques)

• Making the 48-hour report (symptoms of recovery from smoking, handling stress, benefits of quitting, and a review of strategies and techniques)

• Reviewing progress, strategies, and techniques, introducing role play, and practicing techniques for risky situations

• Reviewing progress, strategies, and techniques and educating group members about lifestyle changes

• Celebrating and reviewing strategies and techniques for future abstinence.

This modified group program uses positive reinforcement, learning, and the practice of alternate behaviors and anxiety reduction strategies. Attention is paid to the role of smoking in the lives of those with schizophrenia and its relationship to psychiatric symptoms. Greater tolerance is fostered for intrusive ideation, with the understanding that positive symptoms do not necessarily interfere with learning and group participation. The social and financial limitations of individuals with schizophrenia are considered when designing potential rewards and alternate behaviors and strategies to smoking.

Goldberg (28) has made observations and recommendations about modifying the demands inherent in group treatment for individuals with schizophrenia. New learning often fails to occur because of demands for relatively high-level abilities and skills. Restricted information-processing capacity makes it difficult for an individual with schizophrenia to deal with more than one issue at a time and can also affect decision making. Patients encounter problems with recall and prospective memory and may forget appointments or fail to complete homework tasks. Their attentional difficulties may emerge as a failure to shift to a new topic, or they may become overfocused on one particular detail and lose sight of the overall picture. In addition, they may become bored, restless, or distractible in response to demands for sustained attention for long periods of time. Poor executive functioning includes deficits in the ability to plan, initiate a course of purposeful action, and integrate behavior into meaningful activity.

Several of Goldberg's suggestions were incorporated into the smoking cessation program we designed. They included ensuring that processing demands did not exceed subjects' capacity; presenting three or four choices so that subjects could have some choice without being overwhelmed; using devices for remembering, such as notices, schedules, and diaries, and for organizing and monitoring the correct order of task behaviors; and prompting or using supportive reminder cues, which may be more appropriate than teaching skills or imparting information (28). Often teaching basic skills is redundant because the actual impairments are in the planning and integration functions that lead to skill utilization; overall goal-directed planning is the most important function affected (28). A manual describing the smoking cessation group in more detail is available from the author.

The third smoking cessation program described in the literature for this population is a 15-session manualized treatment called "Smokebusters" (29) developed by Goldberg and his colleagues. The program is based on the principles of the transtheoretical model of stages of change (24), research on smoking and mental illness, and a survey of the needs of 105 smokers with schizophrenia (19). The "Smokebusters" program is designed to provide information, build confidence, and teach practical strategies to enable individuals to change their smoking habits. The first six sessions are intended to facilitate progress from the precontemplation and contemplation stages to the preparation stage of awareness. These sessions focus on the benefits of changing and increasing awareness of members' smoking habits.

Sessions 7 through 12 address barriers to change. Practical strategies for cutting back are taught, so that members can start to experiment with different approaches to changing their smoking behavior. Session 13 is a review and summary of strategies to cope with triggers to smoke. In this session members examine relapse prevention. Promoting a healthy lifestyle and celebrating achievement are the final two sessions in the program. Further information about "Smokebusters" can be obtained from the NOSMO Project of the Hamilton Program for Schizophrenia in Hamilton, Ontario.

Nicotine replacement

The goal of pharmacological intervention in smoking cessation is to suppress withdrawal symptoms. The benefit of nicotine replacement using the transdermal patch has been clearly demonstrated in double-blind clinical trials (30,31). A recent meta-analytic review concluded that use of nicotine patches improved the odds ratio of abstinence to 2.07 (32). The patch has several advantages over nicotine gum. It is easier to use, formulated for once-a-day use, and does not cause gastrointestinal distress.

The only report of using patches for smoking cessation among patients with schizophrenia was from a double-blind crossover study of the effect of nicotine patches in a group of 13 psychiatric patients who were not trying to stop smoking (33). Active and placebo patches were used. Ten subjects had schizophrenia or schizoaffective disorder. Subjects using the active patch achieved a statistically significant reduction in smoking compared with those using the placebo patch. Neither patients nor observers noted any alterations in patients' clinical status. In a letter reporting a potential case of nicotine intoxication, which was not confirmed by blood tests, the symptoms subsided with patch removal and 1 mg of intramuscular lorazepam (34).

The group treatment studies described above (21,22,23) found that successful subjects also used the patch. In the study conducted by my colleagues and me, the standard prescribed patch with a dose of 21 mg was used. Ziedonis and George (21) used an initial dose of 21 mg, but some patients with heavy nicotine dependence received higher doses. Furthermore, in our study the patches appeared to be appropriately used—subjects who began smoking stopped using the patch (23).

Conclusions

People with schizophrenia smoke more than the general population and other psychiatric diagnostic groups. In addition to the health hazards associated with smoking, the use of nicotine may interfere with the benefits of antipsychotic medication and may increase side effects. The majority of patients with schizophrenia receive public financial support that is barely enough for basic survival needs, and the rising costs of tobacco products worsen their already difficult economic situation. The problem of tobacco smoke pollution in psychiatric settings is compounded by the risk of introducing smoking to nonsmokers and the risk of relapse for patients who have quit. Because many smokers with schizophrenia spend much time in the hospital as inpatients or outpatients, helping them stop smoking increases the likelihood of having smoke-free hospitals, which are a benefit to others.

Providing a smoke-free environment for psychiatric patients lags behind efforts for general hospital patients or for patients on other units of general hospitals (17). Smoking by individuals with schizophrenia is often considered acceptable. They are rarely encouraged to stop or supported in their efforts to quit. Finally, the symptoms and the cognitive and social deficits associated with schizophrenia make participation in existing smoking cessation programs difficult for this patient group.

However, three studies have reported promising results in helping individuals with schizophrenia stop smoking (21,22,23). Quitting smoking should not be considered an impossible task for this group, and specific programs have been designed. They are short-term programs lasting from eight to 15 weeks, which is a length of time acceptable to patients. The programs generally do not require additional staff training. Physicians do not need to fear that patients with schizophrenia cannot manage the patch. Finally, the design of these programs clearly addresses the motivational, affective, cognitive, and social impairments often associated with schizophrenia.

Dr. Addington is affiliated with the department of psychiatry at the University of Calgary in Alberta, Canada. Send correspondence to her at the Department of Psychiatry, Foothills Hospital, 1403 29th Street, N.W., Calgary, Alberta, Canada T2N 2T9 (e-mail, [email protected]).