TREATING TOBACCO DEPENDENCE in SMOKERS with CO-OCCURRING SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIE.


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RATES of TOBACCO USE. Smoking rate among people with emotional instability is 2 to 4 x\'s that of the overall public (Hughes, 1993; Poirier, 2002)As numerous as 74% to 88% of people with addictive issue smoke (Kalman, 1998), contrasted with 23% in the all inclusive community (CDC, 2002)Account for 44% to 46% of cigarettes sold in the US (Lasser et al., 2000; Grant et al., 2004).
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TREATING TOBACCO DEPENDENCE in SMOKERS with CO-OCCURRING SUBSTANCE ABUSE OR MENTAL HEALTH DISORDERS: SCIENTIFIC OVERVIEW Judith J. Prochaska, PhD, MPH University of California, San Francisco

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RATES of TOBACCO USE Smoking rate among people with emotional instability is 2 to 4 x " s that of the all inclusive community (Hughes, 1993; Poirier, 2002) As numerous as 74% to 88% of people with addictive issue smoke (Kalman, 1998) , contrasted with 23% in the overall public (CDC, 2002) Account for 44% to 46% of cigarettes sold in the US (Lasser et al., 2000; Grant et al., 2004) 175 billion cigarettes $39 billion in yearly deals

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TRAJECTORIES OF USE Earlier start of smoking Heavier smoking Greater nicotine reliance Greater trouble with stopping Greater psychiatric, psychological, & medicinal comorbidities (e.g., Breslau et al., 1996; Burling et al., 1997; Novy et al., 2001; Richter et al., 2002; Saxon et al., 2003)

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TRENDS in US ADULT SMOKING: 1955–2004 Trends in cigarette smoking among people matured 18 or more established 20.9% of grown-ups are ebb and flow smokers Male Percent Female 22.9% 17.5% Graph gave by the Centers to Disease Control and Prevention. 1955 Current Population Survey; 1965–2004 NHIS. Gauges since 1992 incorporate some time or another smoking.

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SMOKING by DIAGNOSIS 41.0% Overall National Comorbidity Survey 1991-1992 Source: Lasser et al., 2000 JAMA Active

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SMOKING in CALIFORNIA Acton, Prochaska, Kaplan, Small & Hall. (2001) Addict Behav Prochaska, Gill, & Hall. (2004) Psychiatric Services

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TOBACCO KILLS Individuals with emotional sickness kick the bucket, by and large, 25 years rashly ( Colton & Manderscheid, 2006 ) hoisted chance for respiratory and cardiovascular infections and disease, contrasted with age-coordinated controls (Brown et al., 2000; Bruce et al., 1994; Dalton et al., 2002; Himelhoch et al., 2004; Lichtermann et al., 2001; Sokal, 2004). Current tobacco utilize is prescient of future self-destructive conduct, free of depressive manifestations, earlier self-destructive acts, and other substance utilize (Breslau et al., 2005; Oquendo et al., 2004, Potkin et al., 2003).

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TOBACCO & OTHER DRUG USE Half of all passings among people treated for liquor reliance were tobacco-related (Hurt et al., 1996) Death rate 4 times more prominent among long haul medicate abusers who smoke cigarettes versus the individuals who don\'t (Hser et al., 1994) Synergistic wellbeing results of tobacco and other medication utilize: half more noteworthy than the aggregate of each exclusively (Bien & Burge, 1990)

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COMPARATIVE CAUSES of ANNUAL DEATHS in the UNITED STATES Individuals with maladjustment or substance utilize disarranges Number of Deaths (thousands) AIDS Obesity Alcohol Motor Homicide Drug Suicide Smoking Vehicle Induced Source: CDC

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Cardiovascular infection Lung Disease Cancers Delayed mending & recuperation after surgery Dyslipidemia Hypertension Macular degeneration Cataract Osteoporosis Periodontal sickness Sexual brokenness Reduced richness in ladies Poor pregnancy results SIDS, youngster asthma Mental Illness HEALTH RISKS ASSOCIATED with CHRONIC TOBACCO USE

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COMPOUNDS in TOBACCO SMOKE An expected 4,800 mixes in tobacco smoke Gasses (~500 disconnected) Particles (~3,500 segregated) Carbon monoxide Hydrogen cyanide Ammonia Benzene Formaldehyde Nicotine Nitrosamines Lead Cadmium Polonium-210 Arsenic 11 demonstrated human cancer-causing agents

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"LIGHT" CIGARETTES The contrast amongst Marlboro and Marlboro Lights… There are no genuine medical advantages to light cigarettes. Smokers remunerate by either smoking all the more strongly (more profound inward breath) or by hindering the vents. an additional line of ventilation openings Image obligingness of Mayo Clinic Nicotine Dependence Center - Research Program/Dr. Richard D. Harmed The Marlboro and Marlboro Lights logos are enlisted trademarks of Philip Morris USA.

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"NO SAFE" LEVEL of Smoking even 1 to 4 cigarettes a day almost triples the danger of death from coronary illness Smokers who expend less cigarettes can decrease their danger of lung malignancy, yet at the same time confront a much bigger danger of unexpected passing or handicap contrasted and individuals who quit Source: Godtfredsen et al. (2005) JAMA, Bjartveit et al. (2005) Tobacco Control

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QUITTING: HEALTH BENEFITS Time Since Quit Date Circulation enhances, strolling gets to be distinctly simpler Lung work increments up to 30% Lung cilia recover typical capacity Ability to clear lungs of bodily fluid expands Coughing, exhaustion, shortness of breath decline 2 weeks to 3 months 1 to 9 months Excess danger of CHD abatements to a large portion of that of a proceeding with smoker 1 year Risk of stroke is lessened to that of individuals who have never smoked 5 years Lung tumor passing rate drops to a large portion of that of a proceeding with smoker Risk of malignancy of mouth, throat, throat, bladder, kidney, pancreas diminish 10 years Risk of CHD is like that of individuals who have never smoked following 15 years

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YEARS of SURVIVAL GAINED RELATIVE to CONTINUED SMOKING Source: DH Taylor et al., 2002 American Journal of Public Health

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WHY ADDRESS TOBACCO USE in PSYCHIATRIC POPULATIONS? Avoid Death Improve Health Optimize Psychiatric Medication Effects Reduce Isolation Patient $ Savings Tobacco Industry Profits Interest bunches/lawmakers upheld by Tobacco Industry Tax incomes

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WHY do INDIVIDUALS with MENTAL ILLNESS SMOKE? Smoking in immaturity is related with psychiatric issue in adulthood, including: freeze issue, GAD and agoraphobia, wretchedness and self-destructive conduct, substance utilize clutters, and schizophrenia (Breslau et al., 2004; Weiser et al., 2004; Goodman, 2000; Johnson et al., 2000) MENTAL ILLNESS SMOKING Active psychiatric issue are related with every day smoking and movement to nicotine reliance (Breslau et al., 2004).

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FACTORS ASSOCIATED with TOBACCO USE in those with MENTAL ILLNESS Biologic & Pharmacologic Genetic inclination Alleviation of withdrawal Pleasure impacts Weight control Psychological/Behavioral Conditioning impacts Coping instrument Social connections Boredom Tobacco Use Systemic & Treatment Use of cigarettes for support Tobacco industry showcasing endeavors Failure to treat in psychiatry & compulsion treatment settings

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Dopamine Norepinephrine Acetylcholine Glutamate  - Endorphin GABA Serotonin NEUROCHEMICAL and RELATED EFFECTS of NICOTINE N I C O T I N E  Pleasure, compensate  Arousal, hunger concealment  Arousal, intellectual upgrade  Learning, memory improvement  Reduction of uneasiness and pressure  Reduction of nervousness and strain  Mood balance, craving suppr. Benowitz. Nicotine & Tobacco Research 1999;1(suppl):S159–S163.

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DOPAMINE REWARD PATHWAY Prefrontal cortex Dopamine discharge Stimulation of nicotine receptors Nucleus accumbens Ventral tegmental range Nicotine enters mind Amygdala

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Human smokers have expanded nicotine receptors in the prefrontal cortex. High Low Nonsmoker Smoker CHRONIC ADMINISTRATION of NICOTINE: EFFECTS on the BRAIN Image politeness of George Washington University/Dr. David C. Perry et al. J Pharmacol Exp Ther 1999;289:1545–1552.

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GENETIC EFFECTS on NICOTINE METABOLISM 4.4% 0.4% 9.8% Nornicotine Nicotine-1 \'- N - oxide Nicotine glucuronide CYP2A6 Aldehyde oxidase 4.2% ~80% Trans-3\'- hydroxycotinine Trans-3 " - hydroxycotinine Cotinine 13.0% 33.6% Trans-3 " - hydroxycotinine glucuronide Cotinine glucuronide 12.6% Norcotinine 7.4% Cotinine-N - oxide 2.0% Reprinted with authorization, Benowitz et al., 1994. 2.4%

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Source: S.M. Stahl (2000). Basic Psychopharmacology

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Source: S.M. Stahl (2000). Fundamental Psychopharmacology

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NICOTINE ADDICTION CYCLE Reprinted with consent. Benowitz. Med Clin N Am 1992;2:415–437.

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NICOTINE WITHDRAWAL EFFECTS Dysphoric or discouraged mind-set Insomnia and exhaustion Irritability/disappointment/outrage Anxiety or apprehension Difficulty concentrating Impaired assignment execution Increased hunger/weight pick up Restlessness and fretfulness Cravings* Most indications pinnacle 24–48 hr subsequent to stopping and die down inside 2–4 weeks. American Psychiatric Association. (1994). DSM - IV. Hughes et al. (1991). Curve Gen Psychiatry 48:52–59. Hughes & Hatsukami. (1998). Tob Control 7:92 – 93. * Not considered a withdrawal side effect by DSM - IV criteria.

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WHAT is ADDICTION? "Habitual medication use, without medicinal reason, despite negative results" Alan I. Leshner, Ph.D. Previous Director, National Institute on Drug Abuse National Institutes of Health

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SYSTEMIC and TREATMENT FACTORS

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PSYCHIATRISTS in PRACTICE (Himelhoch & Daumit, 2003) 1992-96 Nat\'l Ambulatory Medical Care Survey 23% of psychiatric visits dropped from examination since patient smoking status obscure For patients recognized as smokers (N=1610) Cessation guiding offered at 12% of visits Nicotine Dependence not analyzed at any visit NRT never endorsed

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PSYCHIATRY RESIDENTS\' (N=105) ENGAGEMENT in the 5-As Nationally, just half of Adult Psychiatry Residency Programs give preparing in treating nicotine reliance. Preparing term is a middle of 60 minutes (Prochaska et al., 2006) . Source: Prochaska, Fromont et al., 2005 Acad Psychiatry

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ATTENTION to TOBACCO USE in ADDICTION TREATMENT Absent from most addictions treatment settings 223 dependence treatment programs in Canada: 10% offered formal smoking discontinuance programs 54% announced putting almost no accentuation on smoking 47% still permitted smoking inside (Currie et al., 2003). Hesitance to support smoking ces

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