Topic 6 Assessment
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24 AUGUST 2017PSYCHIATRIC TIMES
www.psychiatr ic t imes.com
» Smita Das, MD, PhD, MPH and Judith J. Prochaska, PhD, MPH
Dr. Das is Clinical Assistant Professor,
D e p a r t m e n t o f P s y c h i a t r y a n d
Behavioral Sciences, Stanford University
School of Medicine; Dr. Prochaska is
Associate Professor of Medicine at the Stan-
ford Prevention Research Center, Stanford
University School of Medicine, Stanford, CA.
CLINICAL SCENARIO: During a routine return medication visit, your patient, a 45-year-old man with bipolar disorder, asks you about using an e-cigarette. You recall that he is a pack-a-day smoker, and when you last dis- cussed his smoking about a year ago, he wanted to quit.
T his clinical scenario is increas- ingly common for psychia- trists. Among people with
mental illness, 15% have tried e-cig- arettes compared with 7% of the gen- eral population, and use rates are on the rise.1 In a study comprising 956 cigarette smokers hospitalized for mental illness, trial use of e-ciga- rettes went from 0% in 2009 to 25% in 2013.2 In the general US popula- tion, among smokers, lifetime use of e-cigarettes increased from 10% in 2010 to 37% in 2013.3
Given the disproportionate burden of tobacco health harms in psychiat- ric patients, e-cigarettes are being considered as a potential tool for harm reduction. This article summa- rizes recent data on e-cigarettes, pro- vides recommendations and resourc- es to learn more, and emphasizes the evidence for treating tobacco (tradi- tional cigarettes) addiction in people with mental illness.
E-cigarettes defined E-cigarettes (ie, vaporizers, vape pens, e-hookah) are battery-operated devices that generate an aerosol from an e-liquid for inhalation. Consisting of a metal tube resembling a tradition- al cigarette, a battery, an atomizer, and a replaceable cartridge, e-cigarettes usually contain liquid nicotine, pro- pylene glycol (an irritant in anti- freeze), glycerin, flavoring, and other
chemicals. A user puffs on an e-ciga- rette, and the heating element aerates the cartridge solution. Many of these are intended to simulate a cigarette. Tank or open systems, discussed be- low, allow users to fill the device with any substance of choice.
Developed and commercialized in China in 2003, e-cigarettes entered the US market in 2006; however, to- bacco companies such as Philip Mor- ris have been researching precursors to e-cigarettes since 1990. Over the past decade, advertising and sales of e-cigarettes have increased exponen- tially every year, and the major tobac- co retailers now dominate the market. While tobacco advertising has been banned from television and radio since 1970, e-cigarettes are promoted widely on these media channels, on the web, and in social media, with many ads reaching youth. In August 2016—10 years after entering the US market—e-cigarettes came under the regulatory authority of the FDA, but regulatory evaluations of the products are still in progress.
E-cigarette concerns Nicotine exposure. Nicotine is a psy- choactive drug that can be addictive. Nicotine delivery with e-cigarettes varies by device (greater with the tank systems than with the cigarette- like products) and by experience level of the user. As the technology improves, the speed and the amount of nicotine absorbed are likely to in- crease over time, along with addic- tion. Mislabeling has been found with nicotine present in products la- beled as nicotine-free or at higher concentrations than labeled.4
Flavors and appeal to youths. Fla- vored options (eg, candy, alcohol, unicorn vomit) can appeal to youth, whose brains are vulnerable to early
addiction exposure. E-cigarettes are widely available for purchase online, in convenience stores, and in neigh- borhood vape shops. Past-month e- cigarette use nearly tripled from 2013 to 2014 among high school stu- dents (4.5% to 13.4%), surpassing all other tobacco use.5 For the first time in decades, the percentage of US youth exposed to any nicotine prod- uct increased, from 2013 to 2014 and again from 2014 to 2015. Moreover, e-cigarettes may be a gateway to con- ventional smoking. Two studies of adolescents who were never-smokers at baseline found that e-cigarette use predicted greater risk of cigarette smoking at follow-up.6,7
Vaping other substances. Modifi- cations to e-cigarettes (“mods”) and open tank systems allow users to vape other substances, most com- monly cannabis oil. In an anonymous study of more than 7000 high school students, nearly 1 in 5 adolescents who use e-cigarettes reported using the device to vape cannabis oil.8
Toxicity and poisoning risks. Nic- otine in high doses, especially in children, can be dangerous and even fatal. Poison control calls for nicotine poisoning have increased from one call in September 2010 to 215 calls per month related to e-cigarette ex- posure in February 2014.9
E-cigarettes: harm reducing? Combustible cigarettes kill two- thirds of long-term smokers.10 E-cig- arettes do not involve combustion; therefore, if a smoker switches to e- cigarettes, carbon monoxide expo- sure and health harms will be re- duced. Yet, the evidence regarding e-cigarettes as a cessation aid is lim- ited; dual use with combustible ciga- rettes is common; and the safety of e-cigarettes has not been established.
Half of current smokers report regular use of e-cigarettes.11 Any use of cigarettes is harmful, and the con- cern is that individuals who use e-cig- arettes will continue to smoke conven- tional cigarettes rather than quit. The strongest evidence in support of e-cigarettes for quitting smoking has come from observational studies in the UK. One study, a time-trend anal- ysis, concluded that for every 1% in- crease in e-cigarette use, the success rate of quit attempts increased by 0.098%.12 In contrast, a second study in the UK found that daily use of e-cigarettes was associated with in- creases in quit attempts and reduc- tions in number of cigarettes smoked, but not with smoking cessation.13
Meta-analyses have been con- ducted to synthesize the findings in the literature. A systematic review of 20 controlled studies concluded that the odds of quitting cigarettes was 28% lower in those who used e-ciga- rettes than in those who did not use e-cigarettes.14 Observational designs are challenged by confounding vari- ables related to who self-selects to use an e-cigarette. Only 2 random- ized controlled trials have evaluated e-cigarettes as a method for quitting conventional cigarettes. The quality of evidence was judged to be low grade, and in both trials, e-cigarettes with nicotine were no different in ef- ficacy for quitting smoking than pla- cebo (nicotine-free) e-cigarettes.15 To date, research does not support the use of e-cigarettes for cessation.
The American Heart Associa- tion’s (AHA) policy statement on e- cigarettes does not recommend their use; however, if a patient has tried and failed evidence-based tobacco cessation methods or is unwilling to try them, the AHA recommends16: • No dual use of traditional cigarettes
with e-cigarettes • That a quit date is also set for the
e-cigarettes
Tobacco and mental illness Smokers with mental illness con- sume nearly half the cigarettes sold in the US and die on average 25 years earlier than the general population, largely from chronic diseases, most tobacco-related. Tobacco use also creates a significant economic bur- den on patients, increases isolation,
E-Cigarettes, Vaping, and Other Electronic Nicotine Products: Harm Reduction Pathways or New Avenues for Addiction?
SIGNIFICANCE FOR THE PRACTICING PSYCHIATRIST
This article summarizes recent data on e-cigarettes, provides recommendations and
resources to learn more, and emphasizes the evidence for treating tobacco addiction
in people with mental illness.
◗ The prevalence of smoking is 2- to 4-fold higher among people with mental illness
than among the general population, and they face tobacco-related disparities in
morbidity and mortality.
◗ With e-cigarette use on the rise, especially among people with mental illness, many
psychiatrists are curious about the risks and potential for abuse with these devices.
SUBSTANCE USE DISORDERS: PART 2
SPEC IAL
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SUBSTANCE USE DISORDERS: PART 2
AUGUST 2017 25PSYCHIATRIC TIMES
www.psychiatr ic t imes.com
E-Cigarettes: Harmful or Harm-Reducing?
https://med.stanford.edu/cme/courses/online/e-cig.html
Stanford Medicine’s online CME focuses on the science of e-cigarettes, partic-
ularly health risks and benefits. Online learners are engaged through video role-
play, expert interviews, and interactive activities. Free registration and 1.5 CME
credits are offered.
RxforChange
http://rxforchange.ucsf.edu
This evidence-based curricula for health care providers is based on the Clinical
Practice Guideline for Treating Tobacco Use and Dependence. Psychiatry
RxforChange is designed for psychiatric providers. With a goal of improving
both the quantity and the quality of tobacco cessation counseling that occurs
in clinical practice, the material is openly shared with free registration.
American Psychiatric Association’s (APA) Council
on Addictions, Tobacco Use Disorders
The goal of this APA workgroup is to inform psychiatrists about tobacco use
and reduce use in patients. The group presented slides from Psychiatry
RxforChange at the APA Annual Meeting in San Diego, CA, in May 2017.
Smokefree.gov
https://smokefree.gov/understanding-smoking/help-others-quit/
resources-health-professionals
The site offers evidence-based smoking cessation tools and content useful
for both researchers and health care providers.
© HAZEM.M.KAMAL /SHUTTERSTOCK.COM
Treating patients with empathy and encouraging the use of NRT can be extremely helpful.
The Sidebar highlights 3 evidence- based accessible clinician resources on e-cigarettes and tobacco cessation treatment. We encourage psychiatrists and other mental health care providers to continue to follow the growing fields of research and regulation on e- cigarettes and tobacco.
Dr. Prochaska has been a consultant for Pfizer,
which makes smoking cessation medications,
and has been an expert witness for plaintiffs’
counsel in court cases against the tobacco
companies.
Acknowledgments: Dr. Prochaska’s research
is funded by the NCI (grant R01CA204356),
the NHLBI (grant R01HL117736), and the
TRDRP (grants 24RT-0035 and 25IR-0032).
References
1. Cummins SE, Zhu SH, Tedeschi GJ, et al. Use of e-
cigarettes by individuals with mental health condi-
tions. Tob Control. 2014;23(suppl 3):48-53.
2. Prochaska JJ, Grana RA. E-cigarette use among
smokers with serious mental illness. PloS One.
2014;9:e113013.
3. King BA, Alam S, Promoff G, et al. Awareness and
ever-use of electronic cigarettes among U.S. adults,
2010-2011. Nicot Tobac. 2013;15:1623-1627.
4. Goniewicz ML, Gupta R, Lee YH, et al. Nicotine lev-
els in electronic cigarette refill solutions: a compara-
tive analysis of products from the U.S., Korea, and
Poland. Int J Drug Policy. 2015;26:583-588.
5. Leventhal AM, Strong DR, Kirkpatrick MG, et al.
Association of electronic cigarette use with initiation
of combustible tobacco product smoking in early
adolescence. JAMA. 2015;314:700-707.
6. Miech R, Patrick ME, O’Malley PM, Johnston LD.
E-cigarette use as a predictor of cigarette smoking:
results from a 1-year follow-up of a national sample
of 12th grade students. Tobac Control. January 2017;
ing the Public Health Service guide- lines of the 5 As—Ask, Advise, As- sess, Assist, Arrange—into regular practice for treating smoking is an evidence-based approach. The AAR method is also effective and takes less than 5 minutes: Asking about smoking, Advising to quit, and Re- ferring to a program.
The national toll-free quit line (1-800-QUIT-NOW) and the Na- tional Cancer Institute’s smokefree. gov website offer evidence-based resources. For patients who are not yet ready to quit smoking, empathy and a focus on the benefits of quit- ting (health, financial, social) are recommended to maintain rapport and raise motivation.
Best practices In the clinical scenario presented at the start, the psychiatrist had not in- quired about tobacco use for a year. It is recommended that psychiatrists assess tobacco use at every visit. Since tobacco use can affect clinical presentation (withdrawal symptoms) and medication levels, asking about tobacco use is clinically indicated. Systems changes (eg, including to- bacco use in a standard assessment, providing clinician prompts) can help integrate tobacco treatment within clinical practice. Further- more, supporting a culture of health where facilities are smoke-free fos- ters the best outcomes for smoking cessation. Smoke breaks should not be promoted nor should clinicians engage in smoking with patients.
and affects the metabolism of a num- ber of psychiatric medications.
Despite the obvious need to treat tobacco addiction, there has been a historic reluctance to do so out of concerns that mental health function- ing may worsen with cessation. In a 2007 AAMC (Association of Ameri- can Medical Colleges) Survey of more than 3000 physicians, psychia- trists were the least likely to address tobacco addiction—although find- ings indicate that psychiatric out- comes improve with tobacco cessa- tion.17,18 The tobacco industry also plays a role by promoting the self- medication hypothesis (ie, that ciga- rettes reduce psychiatric symptoms). However, cigarettes reduce with- drawal symptoms of nicotine rather than psychiatric symptoms. Symp- toms of nicotine withdrawal can mimic psychiatric symptoms (de- pression, insomnia, irritability, anxi- ety, restlessness).
In contrast to the unknowns re- garding e-cigarettes, there are evi- dence-based and well-established cessation treatments that are under- utilized.
Smoking cessation treatment Cessation pharmacotherapy. There are 7 FDA-approved nicotine re- placement therapies (NRTs) that sig- nificantly improve quit rates: 3 over- the-counter NRTs (patch, gum, lozenge); 2 prescription NRTs (spray, inhaler); and 2 oral pills (bupropion, varenicline). NRT reduces nicotine cravings and withdrawal without the reinforcing effects of smoked nico- tine. It is important to educate the patient on the proper use of NRTs. For example, people use the gum like normal chewing gum, when in fact nicotine in the gum is best absorbed in the oral mucosa by parking the gum in the cheek.
Bupropion is well known in psy- chiatry and acts on dopamine, nor- epinephrine, and nicotinic-choliner- gic receptors to decrease cravings and withdrawal symptoms. Vareni- cline is a partial agonist at the α4β2 neuronal nicotinic acetylcholine re- ceptor; it relieves craving and with- drawal and reduces the reinforcing effects of nicotine by blocking dopa- minergic stimulation. The best evi- dence is for varenicline and combina- tion NRT (eg, a patch plus gum or lozenge). The choice of medication depends on history, patient input, cost, previous attempts, and severity of dependence/withdrawal and breakthrough symptoms.
Cessation counseling. Cessation medications are most effective when combined with counseling. Integrat-
Epub ahead of print.
7. Morean ME, Kong G, Camenga DR, et al. High
school students’ use of electronic cigarettes to va-
porize cannabis. Pediatrics. 2015;136:611-616.
8. Rigotti NA. e-Cigarette use and subsequent tobacco
use by adolescents: new evidence about a potential
risk of e-cigarettes. JAMA. 2015;31:673-674.
9. Chatham-Stephens K, Law R, Taylor E, et al. Expo-
sure calls to US poison centers involving electronic
cigarettes and conventional cigarettes: September
2010 to December 2014. J Med Toxicol.
2016;12:350-357.
10. Pirie K, Peto R, Reeves GK, et al. The 21st cen-
tury hazards of smoking and benefits of stopping: a
prospective study of one million women in the UK.
Lancet. 2013;381:133-141.
11. Population Assessment of Tobacco and Health
(PATH) Study Public-Use Files. Inter-University Con-
sortium for Political and Social Research (ICPSR).
2017. http://doi.org/10.3886/ICPSR36498.v3. Ac-
cessed April 28, 2017.
12. Beard E, West R, Michie S, Brown J. Association
between electronic cigarette use and changes in quit
attempts, success of quit attempts, use of smoking
cessation pharmacotherapy, and use of stop smok-
ing services in England: time series analysis of popu-
lation trends. BMJ. 2016;354:i4645.
13. Brose LS, Hitchman SC, Brown J, et al. Is the use
of electronic cigarettes while smoking associated
with smoking cessation attempts, cessation and
reduced cigarette consumption? A survey with a
1-year follow-up. Addiction. 2015;110:1160-1168.
14. Kalkhoran S, Glantz SA. E-cigarettes and smok-
ing cessation in real-world and clinical settings: a
systematic review and meta-analysis. Lancet
Respir Med. 2016;4:116-128.
15. Hartmann-Boyce J, McRobbie H, Bullen C, et al.
Electronic cigarettes for smoking cessation. Co-
chrane Database Syst Rev. 2016;9:CD010216.
16. Bhatnagar A, Whitsel LP, Ribisl KM, et al. Elec-
tronic cigarettes: a policy statement from the Amer-
ican Heart Association. Circulation. 2014;130:
1418-1436.
17. American Association of Medical Colleges. Physi-
cian behavior and practice patterns related to smok-
ing cessation, summary report. Washington, DC:
Association of American Medical Colleges; 2007.
18. Hall SM, Prochaska JJ. Treatment of smokers
with co-occurring disorders: emphasis on integration
in mental health and addiction treatment settings.
Ann Rev Clin Psychol. 2009;5:409-431. ❒
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