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Greetings from Boston, Massachusetts. I am Oliver Freudenreich, or Dr. F as my patients call me, presenting another Quick Take for the Psychopharmacology Institute.
Have you pondered the number of individuals with schizophrenia who smoke today? I have often reflected on this. During my training in the late ’80s, it appeared that a vast majority of those with schizophrenia were smokers. I was then employed at Butner State Hospital in North Carolina—which was my first job when I came to the United States. It felt as though the entire institution revolved around smoking rates. Although many articles discussing the prevalence of smoking among schizophrenia patients are somewhat dated, I have often questioned how we compare with earlier times in terms of progress over the decades. Hence, when I encountered a publication by Beth Han in JAMA Network Open that presented a longitudinal analysis of contemporary smoking rates among patients with psychosis in the U.S., I felt compelled to share this Quick Take.
For an initial query: What is your estimate of the proportion of individuals with psychosis who smoke cigarettes currently? Do you hypothesize it to be 10%, 30%, 50%, or perhaps 70%? To provide some context, I will elaborate on the origins and objectives of this cohort research, termed the PATH study. The acronym denotes Population Assessment of Tobacco and Health. This longitudinal research, sponsored by the U.S. federal government, was initiated to equip the FDA with pertinent data to further their regulatory endeavors concerning tobacco control, propelling our society closer to becoming smoke-free. The data collection comprised annual face-to-face interviews, predominantly comprehensive self-evaluations, to ascertain who smokes, the specific tobacco or nicotine products consumed, and the underlying reasons. The methodology also incorporated certain biomarkers pertinent to smoking. The participant pool embodies a nationally representative sample encompassing adults as well as a segment of youths aged 12–17. The overseeing federal bodies are the NIH and NIDA. This research has spanned over a decade. Its inaugural assessment phase commenced in 2013, and to date, it has traversed seven evaluation cycles, resulting in nearly 1,000 publications. The overarching cohort consistently includes around 30,000 adults, and the initial phase encompassed over 10,000 youth.
The article in question presents data from the fifth wave, spanning 2018–19, focusing specifically on a subset: Those diagnosed with psychosis. Of the approximately 30,000 adults in the cohort, roughly 2.9% were diagnosed with psychosis, which translates to an approximate sample size of 1,200 for this report. The average age of this subset was around 30. Now, to address my earlier question: The PATH study reports that 31% of individuals with psychosis are current smokers—a figure derived from cross-sectional evaluations. This compares with a rate of 19% for the general cohort—a notable difference. The adjusted risk ratio, upon calculation, stands at 1.61.
When considering any tobacco product and not merely cigarettes, the prevalence escalates slightly to 41% vs 28%. The data underscores the multifaceted nature of this issue; patients with psychosis frequently consume cigarettes alongside other nicotine products, such as e-cigarettes. For medical professionals, it becomes imperative to inquire about all forms of nicotine consumption. The research also reiterates the heightened nicotine addiction among those with psychosis and indicates racial disparities. Should you have guessed a 10% smoking rate, you were essentially referencing the prevalent rate across the general populace in numerous states. In Massachusetts, my home state, 11% of adults are current smokers. Conversely, if your estimate was 70%, it suggests that your sample might comprise individuals with myriad risk factors, including poverty, homelessness, psychiatric comorbidity, and potential substance use, leading to elevated prevalence rates.
Broadly, in the U.S., although smoking has diminished as a public health concern, its prevalence remains high among specific subgroups. To phrase this differently, certain subgroups, such as those with psychosis or schizophrenia, continue to be marginalized from this significant public health triumph. This is attributable to multiple vulnerabilities—some psychosocial and potentially some biological. The silver lining is that, on average, a majority of individuals with psychosis no longer smoke, as the prevalence is below 50%. However, a significant minority persists at around 30%. It is crucial to concentrate our efforts on this group, assisting them to either quit smoking or ideally to never commence.
Discussing smoking cessation strategies for patients with psychosis merits an extensive conversation. A salient point I’ve garnered from my addiction group colleagues at MGH emphasizes the paramountcy of pharmacotherapy. The approach has pivoted towards an “opt-out” model, where varenicline, a medication, is recommended to aid cessation as a default strategy, allowing patients the choice to decline. Such a methodology counteracts the ambivalence often seen in highly addicted individuals, ensuring they are afforded a genuine attempt at cessation.
In summary, smoking poses considerable costs—both literal and metaphorical—to patients with psychosis. It depletes a significant portion of their disability allocations and induces medical complications. Prioritizing smoking cessation for these patients is essential. Based on the discussed article, roughly 30% smoke cigarettes, and 40% use any tobacco product—figures that markedly exceed general population rates. It is imperative to meticulously monitor smoking (and other nicotine products) among all patients diagnosed with schizophrenia, offering personalized cessation assistance. By such concerted efforts, we can hope to eliminate this health disparity.
Thank you for your attention.
Abstract
Tobacco Use, Nicotine Dependence, and Cessation Methods in US Adults With Psychosis
Beth Han, Ther W Aung, Nora D Volkow, Marushka L Silveira, Heather L Kimmel, Carlos Blanco, Wilson M Compton
Importance Adults with psychotic disorders have high premature mortality, partly due to the high prevalence of smoking in this population. Yet recent data are lacking on tobacco product use among US adults with a history of psychosis.
Objective To examine the sociodemographic characteristics and behavioral health status; types of tobacco products used; prevalence of use by age, sex, and race and ethnicity; and nicotine dependence severity and smoking cessation methods among community-dwelling adults with vs without psychosis.
Design, Setting, and Participants This cross-sectional study analyzed nationally representative, self-reported, cross-sectional data of adults (aged ≥18 years) who participated in the Wave 5 survey (conducted from December 2018 to November 2019) of the Population Assessment of Tobacco and Health (PATH) Study. Data analyses were conducted between September 2021 and October 2022.
Exposure PATH Study respondents were classified as having lifetime psychosis if they answered yes to whether they had ever received from a clinician (eg, physician, therapist, or other mental health professional) a diagnosis of schizophrenia, schizoaffective disorder, psychosis, or psychotic illness or episode.
Main Outcomes and Measures Use of any and major types of tobacco products, severity of nicotine dependence, and cessation methods.
Results Among the 29 045 community-dwelling adults who participated in the PATH Study (weighted median [IQR] age, 30.0 [22.0-50.0] years; weighted percentage estimates: 14 976 females (51.5%); 16.0% Hispanic, 11.1% non-Hispanic Black, 65.0% non-Hispanic White, and 8.0% non-Hispanic other race and ethnicity [American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and more than 1 race]), 2.9% (95% CI, 2.62%-3.10%) reported receiving a lifetime psychosis diagnosis. Compared with those without psychosis, people with psychosis had a higher adjusted prevalence of past-month any tobacco use (41.3% vs 27.7%; adjusted risk ratio [RR], 1.49 [95% CI, 1.36-1.63]) as well as cigarette smoking, e-cigarette use, and other tobacco product use overall and in most examined subgroups; they also had a higher past-month prevalence of dual cigarette and e-cigarette use (13.5% vs 10.1%; P = .02), polycombustible tobacco use (12.1% vs 8.6%; P = .007), and polycombustible and noncombustible tobacco use (22.1% vs 12.4%; P < .001). Among adults with past-month cigarette use, those with vs without psychosis had a higher adjusted mean nicotine dependence scores overall (54.6 vs 49.5; P < .001) and within the 45-years-or-older (61.7 vs 54.9; P = .002), female (56.9 vs 49.8; P = .001), Hispanic (53.7 vs 40.0; P = .01), and Black (53.4 vs 46.0; P = .005) groups. They were also more likely to make a quit attempt (60.0% vs 54.1%; adjusted RR, 1.11 [95% CI, 1.01-1.21]) and use counseling, a quitline, or a support group for tobacco cessation (5.6% vs 2.5%; adjusted RR, 2.25 [95% CI, 1.21-3.30]).
Conclusions and Relevance In this study, the high prevalence of tobacco use, polytobacco use, and making a quit attempt as well as the severity of nicotine dependence among community-dwelling adults with a history of psychosis highlighted the urgency for tailored tobacco cessation interventions for this population. Such strategies must be evidence-based and age, sex, and race and ethnicity appropriate.
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Reference
Han, B., Aung, T. W., Volkow, N. D., Silveira, M. L., Kimmel, H. L., Blanco, C., & Compton, W. M. (2023). Tobacco use, nicotine dependence, and cessation methods in US adults with psychosis. JAMA Network Open, 6(3), e234995.
