The USPHS Clinical Practice Guidelines16
for the treatment of smoking and TD recommends that physicians, as well as a range of other medical professionals, offer psychological counselling and pharmacotherapy to all smokers wanting to quit. Counselling approaches include self-help programs (printed or electronic materials that are designed to increase motivation and enhance readiness to quit smoking, manage withdrawal symptomatology, and prevent slips and relapses back to smoking), telephone counselling, more intensive CBT approaches, such as individual and group counselling, and health care provider interventions.16,25
CBT integrates cognitive therapies (for example, learning cognitive coping skills to manage negative mood or urges to smoke associated with acute or prolonged nicotine withdrawal), behavioural therapies (for example, changing habits to anticipate and avoid temptations to smoke, and securing extratreatment social support), and motivational therapies (for example, counsellor support and reinforcement of patient-generated reasons for quitting and sustaining abstinence). CBT may be effectively delivered by either a smoking cessation counsellor or a health care provider, involves individual and (or) group counselling, and range in intensity from brief (10- to 15-minute sessions) to intensive (50- to 60-minute sessions). There is a strong positive correlation between total amount of cessation counselling and abstinence.16
Combining CBT with medication is necessary to optimize outcomes. Modifications of CBT for smoking cessation in people with schizophrenia6,26–28
have been developed to deal with the unique needs of MHA smokers.
Recommended first-line smoking cessation therapies include NRTs (nicotine patch, gum, spray, inhaler, and lozenge) and sustained-release bupropion (Zyban), both of which increase odds of quitting about 2-fold, compared with placebo.31,32
Self-administered NRT, such as nicotine gum or inhaler, may deliver systemic nicotine more quickly than the other forms of NRT to target acute cigarette cravings.24,33
Varenicline (Champix, an alpha-4 beta-2 nicotinic acetylcholine receptor partial agonist) was added in the USPHS Clinical Practice Guidelines 2008 update as a recommended first-line medication, and has been found to increase the odds of long-term abstinence about 3-fold, compared with placebo, and 1.5-fold, compared with sustained-release bupropion. For smokers who do not respond to first-line medications, nortriptyline and clonidine are second-line medications that have been shown to offer similar efficacy, compared with NRT and bupropion.32,34
However, owing to their side effect profiles,35,36
caution is recommended with their use.
In response to postmarketing reports of severe adverse events (for example, treatment-emergent psychosis, mania, impulsivity, agitation, and suicidality) associated with use of varenicline, the US Food and Drug Administration37
and Health Canada have advised physicians to monitor their patients taking varenicline for neuropsychiatric symptoms. However, no treatment-related neuropsychiatric symptoms were observed in the varenicline studies of nonpsychiatric smokers38–41
or 2 preliminary studies involving smokers with MHA disorders.42,43
Current studies in the United States, Canada, and Europe are examining the safety and efficacy of varenicline in MHA smokers.