Our patient died 20 years prematurely from complications of pulmonary emphysema due to his use of tobacco. Tobacco smoke remains the leading cause of pulmonary emphysema worldwide (1
). Despite a number of treatment options available to patients with emphysema, including bronchodilators and corticosteroids, smoking cessation is the only intervention with a known mortality benefit (other than oxygen therapy, which is reserved for advanced disease) (1
). Patients who quit smoking can significantly slow the progressive loss of lung function that occurs over time and can decrease the typical respiratory symptoms of cough and shortness of breath associated with this disease.
Tragically, the health care system failed to recognize the patient's serious medical sequelae from his smoking, and his emphysema went undiagnosed until postmortem. That said, Mr. A's heavy use of tobacco was evident for 25 years, yet remained largely untreated.
Nicotine dependence and nicotine withdrawal are recognized by DSM-IV as diagnosable psychiatric disorders; however, rarely are tobacco use and dependence diagnosed and treated in clinical practice (9
). Nicotine dependence is the most prevalent substance use disorder among psychiatric patients, and rates of tobacco use among the mentally ill are two to four times that seen in the general population (11
). It is estimated that 44% of the cigarettes sold in the United States are to individuals with mental illness (11
). Psychiatry needs to recognize nicotine as a powerful addiction and prioritize its treatment to enhance the quality and quantity of our patients' physical and mental well-being.
The APA recommends that psychiatrists assess the smoking status of all patients, including readiness to quit, previous quitting history, and level of nicotine dependence, and provide explicit advice to motivate patients to stop smoking (13
). Evidence-based treatments for tobacco dependence include nicotine-replacement therapy, sustained-release bupropion, varenicline, nortriptyline, clonidine, and psychosocial therapies. Combined therapies (counseling plus pharmacotherapy) are emphasized (14
). Physician advice doubles the rates of patient cessation (15
), and the greater the amount of time spent addressing tobacco use, the more likely the patient is to achieve abstinence (14
). For smokers with active mental illness, integration of smoking-cessation efforts within psychiatric care is recommended (13
Patients with mental illness can be helped to quit smoking. Our recent randomized clinical trial with actively depressed patients recruited from outpatient psychiatry clinics demonstrated significant efficacy in helping patients quit smoking without adverse effects on their mental health recovery (17
). Our meta-analysis of tobacco treatment interventions with smokers in addiction treatment or recovery showed significant posttreatment effects for smoking cessation with enhanced sobriety from drugs and alcohol at long-term follow-up (19
). Of importance, a study with smokers with posttraumatic stress disorder showed a fivefold increase in cessation rates if tobacco treatment services were integrated within ongoing psychiatric care rather than with the provision of a tobacco treatment referral (20
We present this case study to put a face on the dramatic statistics regarding the deadly toll of tobacco use in populations with mental illness and to raise awareness regarding the incredible need for psychiatry to recognize, diagnose, and provide evidence-based treatments for nicotine dependence.