Nicotine dependence

Question 1

Help a woman with well controlled schizophrenia (on olanzapine) overcome her nicotine dependence over a six-week period. The patient is ready to make plans to quit, so does not require interventions that specifically deal with ambivalence about stopping, rather a focussed discussion on the most suitable options and the potential risks

Answer 1

1. Explore reasons for previous unsuccessful attempts to stop smoking.
2. Discuss NRT, one other medication and one non-pharmacological method.
3. Explain the need to decrease dose of olanzapine once she has stopped smoking.
4. explore reinforcers for smoking behaviour and / or identify triggers or high risk smoking situations.
5. demonstrate a detailed understanding of management options for nicotine dependence.
6. provide a succinct overview of all major pharmacological and non-pharmacological options and side effects.
7. recognise the limitations of agents used in smoking cessation.

Question 2

Rates of nicotine dependence in people with mental illness

Answer 2

> 30% compared with 15% without MI

For people with schizophrenia, the rate is up to 66%.

Question 3

Mechanism of nicotine

Answer 3

Nicotine stimulates nicotinic acetylcholine receptors in the mesolimbic pathway to release dopamine in the nucleus accumbens. This leads to positive reinforcement of rewarding behaviour - smoking. Negative reinforcement - relief from withdrawal symptoms - also perpetuates smoking behaviour in those addicted to nicotine. Following repeated exposure, certain situations and activities become associated with the rewards and develop as cues to smoking.

Question 4

Does smoking releive stress

Answer 4

Smoking is often reported by people as being beneficial as it ‘reduces stress’. This is a paradox as multiple studies have identified that cessation of smoking reduces stress, depression, anxiety and improves quality of life. The perceived positive effect of smoking is due to the alleviation of nicotine withdrawal symptoms. Stopping smoking has repeatedly been shown not to exacerbate pre-existing mental illness such as schizophrenia and depression. It is also interesting to note that suicide risk decreases with smoking cessation.

Question 5

Brief overview of options to provide to patients

Answer 5

A range of evidence-based strategies have been shown to improve the implementation of effective smoking cessation interventions, and providing a systematic approach to smoking cessation is associated with higher levels of success. Even brief interventions for smoking cessation (involving opportunistic advice, encouragement and referral) can have positive outcomes, and include one or more of the following:

1) brief advice to stop smoking;
2) an assessment of interest in quitting;
3) offering pharmacotherapy where appropriate;
4) providing self-help material; and
5) offering counselling or referral to external support such as Quitline, an accredited tobacco treatment specialist or other local programs.

The optimal treatment for smoking is combination of counselling, pharmacotherapy and ongoing support. Multiple attempts are not unusual, and when interventions are put in place, the benefits are cumulative with each attempt.

Question 6

Assessing Nicotine Dependence

Answer 6

ASK all patients if they smoke.
ADVISE all smokers to quit in a clear, non-confrontational, personalised way.
ASSESS dependence and readiness to quit.
ASSIST with quitting.
ARRANGE follow up

Question 7

Motivation for change and readiness to quit can be assessed by using key questions:

Answer 7

‘How do you feel about your smoking at the moment?’ and

‘Are you ready to quit now?’

Question 8

CAGE tool to identify dependence

Answer 8

In a modified CAGE questionnaire, two ‘yes’ answers identify a positive screen:
1. Have you ever felt a need to cut down or control your smoking, but had difficulty doing so?
2. Do you ever get annoyed or angry with people who criticise your smoking or tell you that you ought to
quit smoking?
3. Have you ever felt guilty about your smoking or about something you did while smoking?
4. Do you ever smoke within half an hour of waking up (eye-opener)?

Question 9

The ‘Four Cs’ Test

Answer 9

Compulsion:
 Do you ever smoke more than you intend?
 Have you ever neglected a responsibility because you were smoking, or so you could smoke?
Control:
 Have you felt the need to control how much you smoke, but were unable to do so easily?
 Have you ever promised that you would quit smoking, and bought a pack of cigarettes that same day?
Cutting Down (and withdrawal symptoms):
 Have you ever tried to stop smoking? How many times?
 For how long?
 Have you ever had any of the following symptoms when you went for a while without a cigarette: agitation, difficulty concentrating, irritability, mood swings? If so, did the symptom go away after you smoked a cigarette?
Consequences:
 How long have you known that smoking was hurting your body?
 If you continue to smoke, how long do you expect to live? If you were able to quit smoking today and
never start again, how long do you think you might live?