nicotine dependence in the mental health population
DESCRIPTION
Nicotine Dependence in the Mental Health Population. Overview. Neurobiology of addiction Nicotine addiction Nicotine withdrawal Smoking and psychiatric disorders: overview Specific disorders Depression Suicide Schizophrenia Generalized anxiety disorder (GAD) Panic disorder. - PowerPoint PPT PresentationTRANSCRIPT
Nicotine Dependence in the Nicotine Dependence in the Mental Health PopulationMental Health Population
OverviewOverview
Neurobiology of addictionNeurobiology of addiction
Nicotine addictionNicotine addiction
Nicotine withdrawalNicotine withdrawal
Smoking and psychiatric disorders: overviewSmoking and psychiatric disorders: overview
Specific disordersSpecific disorders– DepressionDepression– SuicideSuicide– SchizophreniaSchizophrenia– Generalized anxiety disorder (GAD)Generalized anxiety disorder (GAD)– Panic disorderPanic disorder
Neurobiology of AddictionNeurobiology of Addiction
Stages of AddictionStages of Addiction
Begins with social Begins with social drug taking and acute drug taking and acute reinforcementreinforcement
Pattern of escalating Pattern of escalating compulsive usecompulsive use
DependenceDependence
Le Moal et al. Eur Neuropsychopharmacol. 2007;17:377-393.
Acute Reinforcement/Acute Reinforcement/Social Drug TakingSocial Drug Taking
GeneticGeneticVariablesVariables
Environmental Environmental FactorsFactors
StressStress
Conditioning Conditioning EffectsEffects
Escalating/Compulsive UseEscalating/Compulsive Use
DependenceDependence
WithdrawalWithdrawal
Protracted WithdrawalProtracted Withdrawal
Recovery?Recovery?
RelapseRelapseRelapseRelapse
The 3 major components of the addiction cycle are preoccupation–anticipation, binge–intoxication, and withdrawal–negative affect
The cycle is conceptualized as a spiral that increases in amplitude with repeated experience, ultimately resulting in the pathologic addictive state
Spiraling Cycle of Addiction Spiraling Cycle of Addiction (DSM-IV)(DSM-IV)
Koob. Eur Neuropsychopharmacol. 2003;13:442-452.
Spiraling DistressSpiraling Distress
AddictionAddiction
WithdrawalWithdrawalNegative AffectNegative Affect
WithdrawalWithdrawalNegative AffectNegative Affect BingeBinge
IntoxicationIntoxicationBingeBinge
IntoxicationIntoxication
PreoccupationPreoccupationAnticipationAnticipation
PreoccupationPreoccupationAnticipationAnticipation
Preoccupation with obtainingPreoccupation with obtainingPersistent physical or Persistent physical or
psychological problemspsychological problems
Taken inTaken inlarger amountslarger amountsthan intendedthan intended
Neurocircuits That Underlie AddictionNeurocircuits That Underlie Addiction
NE=norepinephrine, ENK=enkephalin, CRF=corticotropin-releasing factor, DA=dopamine, -END=-endorphin.Le Moal et al. Eur Neuropsychopharmacol. 2007;17:377-393.
Drug-AssociatedDrug-AssociatedReinforcement:Reinforcement:
“Reward” and “Stress”“Reward” and “Stress”
Drug and CueDrug and CueReinstatement:Reinstatement:
“Craving”“Craving” Behavioral Behavioral Output:Output:“Compulsivity”“Compulsivity”
Drug-Seeking BehaviorDrug-Seeking Behavior Motor CortexMotor CortexMotor CortexMotor Cortex
ThalamusThalamusThalamusThalamus
PallidumPallidumPallidumPallidum
Bed Nucleus ofStria TerminalisBed Nucleus ofStria Terminalis
Central Nucleusof Amygdala
Central Nucleusof Amygdala
BasolateralAmygdala
BasolateralAmygdala
Nucleus Accumbens (nAcc)
Nucleus Accumbens (nAcc)
Prefrontal CortexAnterior CingulatePrelimbic Cortex
Orbitofrontal Cortex
Prefrontal CortexAnterior CingulatePrelimbic Cortex
Orbitofrontal Cortex
VTAVTAPontine NucleiPontine Nuclei ArcuateArcuateArcuateArcuate
ENKENK
NENECRFCRF CRFCRF
NENE
ENKENK
DADA
DADAENKENK
DADA-END-END
Neurobiologic Basis for RelapseNeurobiologic Basis for Relapse Relapse occurs in response to stimulation by compulsive drive circuits Relapse occurs in response to stimulation by compulsive drive circuits
and deficits in inhibitory restraintand deficits in inhibitory restraint
Adinoff. Harv Rev Psychiatry. 2004;12:305-320.
Compulsive Drive Compulsive Drive CircuitsCircuits
Inhibitory ControlInhibitory ControlDeficitsDeficits
PrimingPriming
Drug cuesDrug cues
Obsessive thoughts Obsessive thoughts (craving)(craving)
StressStress
Impulsivity Impulsivity (automaticity)(automaticity)
Decision makingDecision making
Summary: Neurobiology of AddictionSummary: Neurobiology of Addiction
Addiction is a multistep processAddiction is a multistep process
Multiple neurocircuits are involved in the craving, reward, Multiple neurocircuits are involved in the craving, reward, stress, and compulsivity associated with addictionstress, and compulsivity associated with addiction
Relapse occurs in response to stimulation by compulsive Relapse occurs in response to stimulation by compulsive drive circuits and deficits in inhibitory restraintdrive circuits and deficits in inhibitory restraint
Nicotine Dependence Nicotine Dependence
Action of nicotine in the central nervous systemAction of nicotine in the central nervous system
Neurobiologic and physiologic effects of Neurobiologic and physiologic effects of tobacco dependence tobacco dependence
Nicotine Dependence: Nicotine Dependence: DSM-IV-TRDSM-IV-TR Criteria Criteria
3 or more of the following symptoms 3 or more of the following symptoms within a 1-year time span:within a 1-year time span:– Tolerance to nicotine with Tolerance to nicotine with
decreased effect and increasing decreased effect and increasing dose to obtain same effectdose to obtain same effect
– Withdrawal symptoms with Withdrawal symptoms with cessationcessation
– Persistent desire to smoke despite Persistent desire to smoke despite efforts to decrease intakeefforts to decrease intake
– Extensive time spent smoking or Extensive time spent smoking or purchasing tobaccopurchasing tobacco
– Postponing work, social, or Postponing work, social, or recreational events in order to recreational events in order to smokesmoke
– Continuing to smoke despite health Continuing to smoke despite health hazardshazards
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision. Washington, DC: American Psychiatric Association; 2000; http://www.intox.org/databank/documents/supplem/supp/sup2.htm. Accessed October 19, 2007.
N
N CH3
NicotineNicotine
Neuronal Nicotine Acetylcholine Neuronal Nicotine Acetylcholine ReceptorReceptor Nicotine binds preferentially to nicotinic acetylcholinergic receptors Nicotine binds preferentially to nicotinic acetylcholinergic receptors
(nAchRs) in the central nervous system(nAchRs) in the central nervous system
When nicotine binds to the nAChR, the receptor complex undergoes When nicotine binds to the nAChR, the receptor complex undergoes a conformational change, allowing the channel gate to open, permitting a conformational change, allowing the channel gate to open, permitting the passage of cations, resulting in signal transmissionthe passage of cations, resulting in signal transmission
Laviolette et al. Nat Rev Neurosci. 2004;5:55-65.
PreterminalPreterminalnAChRsnAChRs
PresynapticPresynapticnAChRsnAChRs
PostsynapticPostsynapticnAChRsnAChRs
H2N
Ligand binding site
COOH
Cytoplasmic
Extracellular M1
M4
M2M3
COOH
NH2H2N
HOOC
A B
C
Mechanism of Action of Nicotine in the Mechanism of Action of Nicotine in the Central Nervous SystemCentral Nervous System
The The 442 nicotinic receptor in the VTA mediates the effects of nicotine in 2 nicotinic receptor in the VTA mediates the effects of nicotine in the central nervous systemthe central nervous system
After nicotine binds to the After nicotine binds to the 442 nicotinic receptor in the VTA, it results in a 2 nicotinic receptor in the VTA, it results in a release of dopamine in the nAcc, which is believed to be linked to rewardrelease of dopamine in the nAcc, which is believed to be linked to reward
nAcc= Nucleus Accumbens. Adapted from Picciotto et al. Nicotine Tob Res. 1999;1:S121-S125.
Nicotine -
Dopamine -
4 2224
42Nicotinic receptor
nAcc
Ventraltegmental area
(VTA)
NICNICNICNIC
Nicotine Stimulates Dopamine Release Nicotine Stimulates Dopamine Release
Nicotine activates Nicotine activates 442 nicotinic receptors in the VTA, resulting in 2 nicotinic receptors in the VTA, resulting in dopamine release at the nAcc. This may result in the short-term dopamine release at the nAcc. This may result in the short-term reward/satisfaction associated with cigarette smokingreward/satisfaction associated with cigarette smoking
nAcc= Nucleus Accumbens; VTA= Ventral Tegmental Area. Adapted from Picciotto et al. Nicotine Tob Res. 1999;1:S121-S125.
D
D
D
D
D – β2 subunitcontaining nAChR
Nicotine Dopamine
VTA nAcc
AxonD Reward
Role of Dopamine in Nicotine AddictionRole of Dopamine in Nicotine Addiction
Rewarding effects of nicotine Rewarding effects of nicotine are dependent on mesolimbic are dependent on mesolimbic dopamine-mediated dopamine-mediated transmissiontransmission
In nicotine-dependent patients, In nicotine-dependent patients, the drive for continued drug use the drive for continued drug use results from the need for results from the need for heightened dopamine heightened dopamine concentrationsconcentrations
Adinoff. Harv Rev Psychiatry. 2004;12:305-320. http://www.biopsychiatry.com/dopamine/dopamine.jpg. Accessed May 1, 2007.
OH
OH
NH2
Dopamine
Chronic Nicotine Exposure: Chronic Nicotine Exposure: Up-Regulation of Nicotine Receptors Up-Regulation of Nicotine Receptors With chronic exposure, nicotine stimulates With chronic exposure, nicotine stimulates 442 nicotinic receptor 2 nicotinic receptor
activation and desensitization, followed by activation and desensitization, followed by 442 nicotinic receptor up-2 nicotinic receptor up-regulation and an increase in the number of regulation and an increase in the number of 442 nicotinic receptors2 nicotinic receptors
Adapted from Picciotto et al. Nicotine Tob Res. 1999;1:S121-S125; Corringer et al. J Phys Paris. 2006;99:162-171.
VTA nAcc
D – β2 subunitcontaining nAChR
Nicotine Dopamine
RewardAxon
D
D
D
D
D
D
DD
D
D
The Cycle of Nicotine AddictionThe Cycle of Nicotine Addiction
Nicotine binding causes an increase in Nicotine binding causes an increase in release of dopaminerelease of dopamine
Dopamine gives feelings of pleasure Dopamine gives feelings of pleasure and calmand calm
The dopamine decrease between The dopamine decrease between cigarettes leads to withdrawal cigarettes leads to withdrawal symptoms of irritability and stresssymptoms of irritability and stress
The smoker craves nicotine to restore The smoker craves nicotine to restore pleasure and calmnesspleasure and calmness
Smokers generally titrate their smoking Smokers generally titrate their smoking to achieve maximal stimulation and to achieve maximal stimulation and avoid symptoms of withdrawal and avoid symptoms of withdrawal and cravingcraving
Jarvis. BMJ. 2004;328:277-279; Picciotto et al. Nicotine Tob Res. 1999;1:S121-S125.
DopamineDopamine
NicotineNicotine
Role of Environmental Stimuli in Nicotine Role of Environmental Stimuli in Nicotine DependenceDependence
Environmental/social stimuli associated with smoking Environmental/social stimuli associated with smoking play a role in reinforcing nicotine dependenceplay a role in reinforcing nicotine dependence
Nonnicotine stimuli are important in both motivating and Nonnicotine stimuli are important in both motivating and maintaining smoking behaviormaintaining smoking behavior
Role of environmental vs pharmacologic stimuli in Role of environmental vs pharmacologic stimuli in nicotine dependence varies between men and womennicotine dependence varies between men and women
Direct pharmacologic effects of nicotine are necessary but not Direct pharmacologic effects of nicotine are necessary but not sufficient to explain tobacco dependence; these effects sufficient to explain tobacco dependence; these effects must take into account the environmental/social context must take into account the environmental/social context
in which the behavior occursin which the behavior occurs
Direct pharmacologic effects of nicotine are necessary but not Direct pharmacologic effects of nicotine are necessary but not sufficient to explain tobacco dependence; these effects sufficient to explain tobacco dependence; these effects must take into account the environmental/social context must take into account the environmental/social context
in which the behavior occursin which the behavior occurs
Caggiula et al. Physiol Behav. 2002;77:683-687.
Summary: Nicotine DependenceSummary: Nicotine Dependence
Nicotine dependence is a well-defined addictive disorderNicotine dependence is a well-defined addictive disorder
Nicotine’s effects on the Nicotine’s effects on the 442 receptors in the Ventral 2 receptors in the Ventral Tegmental Area (VTA) results inTegmental Area (VTA) results in– Acute dopamine release and short-term rewardAcute dopamine release and short-term reward– Chronic receptor activation, desensitization, and Chronic receptor activation, desensitization, and
up-regulation up-regulation
The dopaminergically mediated physical and The dopaminergically mediated physical and psychological rewards of smoking reinforce repeat psychological rewards of smoking reinforce repeat behaviorbehavior
Environmental/social stimuli associated with smoking Environmental/social stimuli associated with smoking play a role in reinforcing nicotine dependenceplay a role in reinforcing nicotine dependence
Nicotine Withdrawal Nicotine Withdrawal
‘‘Why do people smoke . . . to relax; for the taste; to fill the time; something to do with my hands. . . . But, for the most part, people continue to smoke because they find it too uncomfortable to quit’’
Philip Morris, 1984
Philip Morris. Internal presentation. 1984, 20th March; Kenny et al. Pharmacol Biochem Behav. 2001;70:531-549.
Nicotine WithdrawalNicotine Withdrawal
Restlessness or impatience
Increased appetite or weight gain
Withdrawal Syndrome
Anxiety(may increase
or decrease with quitting)
Dysphoric or depressed mood
Irritability, frustration,
or anger
Difficulty concentrating
Insomnia/sleep disturbance
Nicotine withdrawal syndrome consists of both somatic and affective Nicotine withdrawal syndrome consists of both somatic and affective symptomatologysymptomatology
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision. Washington, DC: American Psychiatric Association; 2000.
0.0
0.5
1.0
1.5
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
Anxiety/TensionAnxiety/Tension
Irritability/AngerIrritability/Anger
Excessive HungerExcessive Hunger
Select Withdrawal Symptoms Over TimeSelect Withdrawal Symptoms Over Time
N = 40. Mean adjusted withdrawal scores are from an analysis of covariance with baseline cigarettes per day and baseline scores on the items shown as covariates. Gross et al. Psychopharmacology. 1989;98:334-341.
ImpatienceImpatience
0.0
0.5
1.0
1.5
1 2 3 4 5 6 7 8 9 10
PlaceboPlacebo Nicotine GumNicotine Gum
Mea
n A
dju
sted
Mea
n A
dju
sted
Wit
hd
raw
al S
core
Wit
hd
raw
al S
core
Mea
n A
dju
sted
Mea
n A
dju
sted
Wit
hd
raw
al S
core
Wit
hd
raw
al S
core
Postcessation WeeksPostcessation Weeks
0.0
0.5
1.0
1.5
0.0
0.5
1.0
1.5
1 2 3 4 5 6 7 8 9 10
Postcessation WeeksPostcessation Weeks
Postcessation WeeksPostcessation WeeksPostcessation WeeksPostcessation Weeks
Nicotine Withdrawal: SeverityNicotine Withdrawal: Severity
aClasses of withdrawal syndrome are defined by groups of respondents who endorsed similar combinations of symptoms. Estimates of prevalence for different classes of withdrawal were obtained along with expected frequencies of endorsement for each symptom of withdrawal by type.Madden et al. Addiction. 1997;92(7):889-902.
Smokers experiencing severe withdrawal have the most pronounced Smokers experiencing severe withdrawal have the most pronounced symptoms of depressionsymptoms of depression
Cravin
g Nico
tine
Irrita
bility
Nervo
usne
ss
Restle
ssne
ss
Poor C
once
ntra
tion
Heada
ches
Feelin
g Dro
wsy
Upset
Sto
mac
h
Heart
Slowed
Dow
n
Incr
ease
d App
etite
Hands
Sha
king
Depre
ssed
Moo
d
Troub
le Slee
ping
En
do
rsem
ent
Pro
bab
ility
En
do
rsem
ent
Pro
bab
ility
aa
0.0
0.9
1.0
0.8
0.7
0.6
0.5
0.4
0.1
0.2
0.3
Mild
Moderate
Severe
Withdrawal Symptoms
3.91
16.2921.81
6.28 6.42
0
10
20
30
40
50
60
70
Severity of Withdrawal and Psychiatric Severity of Withdrawal and Psychiatric Disorders Disorders
aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons.Madden. Addiction. 1997;92(7): 889-902.
Smokers with a history of psychiatric disorders have a higher likelihood Smokers with a history of psychiatric disorders have a higher likelihood of experiencing severe withdrawalof experiencing severe withdrawal
Alcohol Dependence
Conduct Disorder
AgoraphobiaMajor Depression
SocialPhobia
Od
ds
Rat
io (
95%
CI)
Od
ds
Rat
io (
95%
CI)
aa
Summary: Nicotine WithdrawalSummary: Nicotine Withdrawal
Nicotine withdrawal syndrome consists of both somatic Nicotine withdrawal syndrome consists of both somatic and affective symptomatologyand affective symptomatology
Smokers experiencing severe withdrawal have the most Smokers experiencing severe withdrawal have the most pronounced symptoms of depressionpronounced symptoms of depression
Smokers with a history of psychiatric disorders have a Smokers with a history of psychiatric disorders have a higher likelihood of experiencing severe withdrawalhigher likelihood of experiencing severe withdrawal
Smoking and Psychiatric Disorders: Smoking and Psychiatric Disorders: OverviewOverview
Prevalence of Smoking in the Psychiatric Prevalence of Smoking in the Psychiatric PopulationPopulation
39.1
55.359.0%
0
10
20
30
40
50
60
70
No PsychiatricDisorder
Lifetime PsychiatricDisorder
Past-MonthPsychiatric Disorder
Lasser et al. JAMA. 2000;284(20):2606-2610.
Lif
etim
e S
mo
kin
g R
ates
(%
)L
ifet
ime
Sm
oki
ng
Rat
es (
%)
PP<.001<.001
PP<.001<.001
22.6
26.2
20
21
22
23
24
25
26
27
Current Smokers WithoutPsychiatric Disorders in the Past
Month (n=746)
Current Smokers With PsychiatricDisorders in the Past Month
(n=511)
Increased Cigarette Consumption in Increased Cigarette Consumption in Smokers With Psychiatric DisordersSmokers With Psychiatric Disorders
Lasser et al. JAMA. 2000;284(20):2606-2610.
Cig
aret
tes/
Day
Cig
aret
tes/
Day
Underdiagnosis of “Nicotine Underdiagnosis of “Nicotine Dependence” in the Psychiatric SettingDependence” in the Psychiatric Setting
88
20
20
40
60
80
100
Tobacco Use Diagnosed NicotineDependence
Peterson et al. Am J Addict. 2003;12:192-197.
Do
cum
ente
d (
%)
Do
cum
ente
d (
%)
Mental Health RecordsMental Health Records
4.4
2.63.63.2
0.0
3.0
6.0
9.0
Smoking: Risk Factor for Psychiatric Smoking: Risk Factor for Psychiatric DisordersDisorders
GAD=generalized anxiety disorder. These models predict the subsequent onset of specific disorders in all daily smokers, without controlling for other psychiatric disorders that preceded the onset of daily smoking and without taking into account the proximity and intensity of smoking.aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons. bFrom a series of 10 survival models for first onset of specific disorders associated with prior daily smoking as time dependent, adjusted for race, sex, age, education, and same-year onset. cP.05.Breslau et al. Psychol Med. 2004;34:323-333.
Major Depression
AgoraphobiaDysthymia
Od
ds
Rat
io (
95%
CI)
Od
ds
Rat
io (
95%
CI)
a,b
,ca,
b,c
Estimated effects of preexisting daily smoking varies across disordersEstimated effects of preexisting daily smoking varies across disorders
Panic Disorder
2.42.9
1.41.1
0.0
1.0
2.0
3.0
4.0
5.0
Major Depression Any Anxiety
Dependent smokers vs nonsmokers
Nondependent smokers vs nonsmokersaThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons; sex adjusted. bAdjusted for other substance dependencies.Breslau. Behav Genet. 1995;25(2):95-101.
Psychiatric Disorders in Dependent and Psychiatric Disorders in Dependent and Nondependent SmokersNondependent Smokers
Od
ds
Rat
io (
95%
CI)
Od
ds
Rat
io (
95%
CI)
aa
b b
The associations of psychiatric disorders with tobacco dependence are The associations of psychiatric disorders with tobacco dependence are stronger than with nondependent smokingstronger than with nondependent smoking
2.2
1.41.8 1.8
0.0
1.0
2.0
3.0
4.0
Psychiatric Disorders: Odds of Psychiatric Disorders: Odds of Progression to Nicotine DependenceProgression to Nicotine Dependence
Major Depressionb
Agoraphobiab GADcPanicDisorder
Od
ds
Rat
io (
95%
CI)
Od
ds
Rat
io (
95%
CI)
aa
aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons. Preexisting disorder is defined as first onset at least 1 year before onset of daily smoking. bP<.05.cGAD= Generalized Anxiety DisorderBreslau et al. Biol Psychiatry. 2004;55:69-76.
Psychiatry and SmokingPsychiatry and Smoking
Psychiatric patients who smoke Psychiatric patients who smoke havehave
2.9
22.3
0
10
20
30
Nonsmokers Current Smokers
%%
– Higher incidence of Higher incidence of illicit drug useillicit drug use
– Poorer treatment Poorer treatment compliancecompliance
– Lower Global Assessment Lower Global Assessment Functioning (GAF) scoreFunctioning (GAF) score
%%G
AF
Sco
re
GA
F S
core
505
0
P=.0000
P=.0000
P=.000
Montoya et al. Am J Addict. 2005;14(5):441-454.
16.3
39.0
0
20
40
60
Nonsmokers Current Smokers
30.9
52.3
0
20
40
60
Nonsmokers Current Smokers
Illicit Drug UseIllicit Drug Use
Noncompliant With TreatmentNoncompliant With Treatment
Nicotine Addiction: Social and Nicotine Addiction: Social and Psychological FactorsPsychological Factors
SmokingSmoking
– Accepted part of the culture in Accepted part of the culture in many psychiatric treatment many psychiatric treatment facilitiesfacilities
– Shared social activity Shared social activity
– Barrier to achieving Barrier to achieving relationships, employment, and relationships, employment, and housing for psychiatric patientshousing for psychiatric patients
Williams et al. Addict Behav. 2004;29:1067-1083; Reuters UK. http://uk.reuters.com/article/personalFinanceNews/idUKNOA82640920070629. Accessed September 25, 2007.
Smoking and Psychiatric Smoking and Psychiatric SymptomatologySymptomatology
In patients with schizophrenia, In patients with schizophrenia, smoking may be associated smoking may be associated with improvements in specific with improvements in specific symptoms and cognitive symptoms and cognitive measuresmeasures
Compton et al. Harv Rev Psychiatry. 2006;14(4):212-222; Depressed Man_PRinc_SF8575_Reference. http://db2.photoresearchers.com/search/SF8575. Accessed September 28, 2007.
Summary: Smoking and Psychiatric Summary: Smoking and Psychiatric DisordersDisorders
Smoking is highly prevalent in the psychiatric populationSmoking is highly prevalent in the psychiatric population
Nicotine-dependent smokers in the mental health populationNicotine-dependent smokers in the mental health population– Smoke greater quantitiesSmoke greater quantities– Frequently are underdiagnosedFrequently are underdiagnosed– Have a higher incidence of illicit drug use, poorer treatment Have a higher incidence of illicit drug use, poorer treatment
compliance, and lower GAF scorescompliance, and lower GAF scores– May derive symptomatic relief from their psychiatric disorders May derive symptomatic relief from their psychiatric disorders
as a result of smokingas a result of smoking
Estimated effects of preexisting daily smoking varies across Estimated effects of preexisting daily smoking varies across disordersdisorders
Active psychiatric disorders may predict an increased risk of Active psychiatric disorders may predict an increased risk of smokers’ progression to nicotine dependencesmokers’ progression to nicotine dependence
Numerous social and psychological factors play a role in the Numerous social and psychological factors play a role in the perpetuation of nicotine dependence in the mentally illperpetuation of nicotine dependence in the mentally ill
Smoking and DepressionSmoking and Depression
26%
26%
Prevalence of DepressionPrevalence of Depression In the United Kingdom, 56% of patients with depression are regular In the United Kingdom, 56% of patients with depression are regular
smokers, which is more than double the prevalence rate (26%) in smokers, which is more than double the prevalence rate (26%) in the general populationthe general population
44%
56%
Farrell et al. Int Rev Psychiatry. 2003;15:43-49; Mackay et al. The Tobacco Atlas. 2nd ed. 2006.
Depressed PatientsDepressed Patients General PopulationGeneral Population
Current SmokersNonsmokers
Risk of Depression in Adolescent Risk of Depression in Adolescent SmokersSmokers
1.0
3.9
0123456789
Nonsmokers Current Smokers
aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons. bThose scoring above the cutpoints for the modified Centers for Epidemiologic Studies-Depression Scale (CES-D) were considered to have high depressive symptomatology.Goodman et al. Pediatrics. 2000;106(4):748-755..
Od
ds
Rat
io (
95%
CI)
Od
ds
Rat
io (
95%
CI)
aa
In nondepressed adolescents, current cigarette smoking was the In nondepressed adolescents, current cigarette smoking was the strongest predictor of developing high depressivestrongest predictor of developing high depressivebb symptoms symptoms
Smoking Affects Psychomotor Smoking Affects Psychomotor PerformancePerformance
aMean reaction time was measured using a computer-based simple reaction time task. Malpass et al. Psychopharmacology. 2007;190:363-372.
Depressed Smokers
Mea
n R
eact
ion
Tim
e (m
s)M
ean
Rea
ctio
n T
ime
(ms)
aa
400400
380380360360
340340320320
300300280280
260260
00 11 22 33CigaretteCigarette
Mea
n R
eact
ion
Tim
e (m
s)M
ean
Rea
ctio
n T
ime
(ms)
aa
400400
380380360360
340340320320
300300280280
260260
00 11 22 33CigaretteCigarette
Control Smokers
PrePre PostPost
Quitting and DepressionQuitting and Depression
Smokers with a history of Smokers with a history of depression are less likely depression are less likely to quitto quit
Even minimal levels of Even minimal levels of depression can affect abstinence depression can affect abstinence after an attempt to quitafter an attempt to quit
POMS=Profile of Mood State is a 65-item measure designed to assess a patient’s current mood state.Niaura et al. Psychol Addict Behav. 2001;15:13-17.
Cu
mu
lati
ve P
rop
ort
ion
Su
rviv
ing
Cu
mu
lati
ve P
rop
ort
ion
Su
rviv
ing
1.01.00.90.90.80.80.70.70.60.60.50.50.40.40.30.30.20.20.10.10.00.0
00 55 1010 1515 2020 2525 3030
Days to First CigaretteDays to First Cigarette
PP<.01<.01
POMS Depression 0POMS Depression 0
POMS Depression POMS Depression 11
Summary: Smoking and DepressionSummary: Smoking and Depression
Smoking is highly prevalent in patients who have Smoking is highly prevalent in patients who have depressiondepression
Patients with depression may smoke to ameliorate their Patients with depression may smoke to ameliorate their depressive symptomsdepressive symptoms
Depressed smokers are less likely to successfully quit Depressed smokers are less likely to successfully quit smokingsmoking
Smoking and SuicideSmoking and Suicide
Increased Rate of Suicide in SmokersIncreased Rate of Suicide in Smokers
Doll et al. BMJ. 1994;309:901-911.
There is a strong association between heavy smoking and high suicide rate
2329
2633
57
0
20
40
60
An
nu
al S
uic
ide
Rat
e p
er 1
00,0
00
An
nu
al S
uic
ide
Rat
e p
er 1
00,0
00
by
Cig
aret
tes
Sm
oke
d/D
ayb
y C
igar
ette
s S
mo
ked
/Day
Current SmokersCigarettes/Day
2515-24Ex-smokersNever Smokers 1-14
Men
Smoking and Suicide: Increased RiskSmoking and Suicide: Increased Risk
1.0 1.4
2.5
4.3
0
2
4
6
8
10
aRelative risk was defined as the suicide incidence rate among those with a history of smoking divided by the rate among nonsmokers. Adjusted for time period, age, alcohol intake, and marital status. Miller et al. Am J Public Health. 2000;90:768-773.
Rel
ativ
e R
isk
Rel
ativ
e R
isk (9
5% C
I)(9
5% C
I)aa
Never Smokers Ex-smokers 1-14 (n=1333) 15 (n=2241)
PP<.001<.001
Cigarettes/DayCurrent Smokers
1.82
1.091.00
0.0
1.0
2.0
3.0
Never Smokers Ex-smokers Current Smokers
Increased Risk of Suicidal BehaviorIncreased Risk of Suicidal Behavior
aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed person. Adjusted for history of major depression, alcohol, and drug use disorders.Breslau et al. Arch Gen Psychiatry. 2005;62:328-334.
Od
ds
Rat
io (
95%
CI)
Od
ds
Rat
io (
95%
CI)
aa Tobacco use is associated with an increased risk in suicidal behavior among adolescents and Tobacco use is associated with an increased risk in suicidal behavior among adolescents and
adults, independent of other substance use, depressive symptoms, and prior suicidal ideationadults, independent of other substance use, depressive symptoms, and prior suicidal ideation
PP<.05<.05
1.001.00
2.05
1.592.31
3.63
0
2
4
6
8
10
Smoking and Suicide: Smoking and Suicide: Violent vsViolent vsNonviolent DeathsNonviolent Deaths Smoking is associated with an increased risk of both violentSmoking is associated with an increased risk of both violent
and nonviolent suicideand nonviolent suicide
aThe probability of an event (developing a disease) occurring in exposed people compared with the probability of the event in nonexposed people.Tanskanen et al. Acta Psychiatr Scand. 2000;101:243-245.
Rel
ativ
e R
isk
(95%
CI)
Rel
ativ
e R
isk
(95%
CI)
aa
Violent Suicides Nonviolent Suicides
Light/moderate smokers
Heavy Smokers
Nonsmokers
P=.03
P<.01
P=.05
P<.01
Suicidal Behavior and SerotoninSuicidal Behavior and Serotonin
Inverse relationship between Inverse relationship between the quantity of cigarettes the quantity of cigarettes smoked and CSF 5-HIAA smoked and CSF 5-HIAA (index of serotonin function) (index of serotonin function) ((PP.003).003)
Reduced CSF 5-HIAA Reduced CSF 5-HIAA concentration is independently concentration is independently associated withassociated with– History of a higher lethality in History of a higher lethality in
suicide attemptssuicide attempts– Severity of lifetime aggressionSeverity of lifetime aggression
CSF 5-HIAA=cerebrospinal fluid 5-hydroxyindoleacetic acid. Malone et al. Am J Psychiatry. 2003;160:773-779; Placidi et al. Biol Psychiatry. 2001;50:783-791.
CS
F 5
-HIA
A (
pm
ol/
mL
)C
SF
5-H
IAA
(p
mo
l/m
L)
0
20
40
60
80
100
120
0 1-20 21-39 40
Cigarettes/DayCurrent Smokers
Adolescent Psychiatric Inpatients: Adolescent Psychiatric Inpatients: Smoking and SuicideSmoking and Suicide
aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons.Mäkikyrö et al. J Adolesc Health. 2004;34:250-253.
1.00 0.64
4.33
0
4
8
12
16
None Obvious/Life-Threatening Attempts
Ambivalent/Mild Attempts
Od
ds
Rat
io (
95%
CI)
Od
ds
Rat
io (
95%
CI)
aa
Regular Daily Smoking
Nicotine Dependence: Increased Suicide Nicotine Dependence: Increased Suicide RiskRisk
Harris et al performed a statistical Harris et al performed a statistical overview of the medical literature to overview of the medical literature to estimate the suicide risk associated estimate the suicide risk associated with common mental disorderswith common mental disorders
A standardized mortality ratio (SMR)A standardized mortality ratio (SMR)aa was calculated for each disorderwas calculated for each disorder
Nicotine dependence had a Nicotine dependence had a significantly raised SMR, 244 significantly raised SMR, 244 (207-286)(207-286)
There appears to be a distinct There appears to be a distinct association between smoking and association between smoking and suicidesuicide
aSMR is an indirect method of adjusting a rate. It is defined as the number of observed deaths (in the cohort) divided by the number of expected deaths. The expected number of deaths in the reference population by age group is applied to the number of persons in each age group in the study population to obtain the expected number of deaths in this population.Harris et al. Br J Psychiatry. 1997;170:205-228; CNN.com. http://archives.cnn.com/2000/HEALTH/children/10/03/teen.smoking.ap. Accessed September 25, 2007.
SmokingSmoking––Suicide Connection: Possible Suicide Connection: Possible ExplanationsExplanations
Smoking – Is a form of self-medication for depression, a common
antecedent of suicide– Alters brain chemistry, leading to depression, which
increases the risk of suicide– Is associated with an increased risk of cancer, which
increases the risk of suicide– Is associated with other characteristics that predispose
individuals to suicide (eg, low self-esteem)
Miller et al. Am J Public Health. 2000;90:768-773.
Summary: Smoking and SuicideSummary: Smoking and Suicide
Positive association between smoking and suicidePositive association between smoking and suicide
Smoking is associated with an increased risk ofSmoking is associated with an increased risk of– Suicidal behavior among adolescents and adults, Suicidal behavior among adolescents and adults,
independent of other substance use, depressive symptoms, independent of other substance use, depressive symptoms, and prior suicidal ideationand prior suicidal ideation
– Both violent and nonviolent suicideBoth violent and nonviolent suicide
Inverse relationship between smoking and indices of Inverse relationship between smoking and indices of serotonin functionserotonin function
There are multiple possible explanations for the There are multiple possible explanations for the suicidesuicide––smoking connectionsmoking connection
Smoking and SchizophreniaSmoking and Schizophrenia
Smoking and SchizophreniaSmoking and Schizophrenia
Among the mentally ill, smoking prevalence is highest in patients with schizophrenia (~70%-90%)
Schizophrenic patients smoke at nearly 3 times the rate of the general population
Smokers with schizophrenia experience increased– Psychiatric symptoms– Number of hospitalizations– Medication doses
Williams et al. Addict Behav. 2004;29:1067-1083; Dalack et al. Am J Psychiatry. 1998;155:1490-1501; http://www.istockphoto.com/file_closeup/who/character_traits/weakness/2700932_temporary_solution.php?id=2700932. Accessed October 11, 2007.
Financial Implications of Smoking Financial Implications of Smoking Among Schizophrenic PatientsAmong Schizophrenic Patients
Steinberg et al. Tob Control. 2004;13:206-208.
27.4%
72.6%
Cigarettes
Food, Shelter, Other
Monthly BudgetMonthly Budget
Smoking imposes a significant financial burden on patients with Smoking imposes a significant financial burden on patients with schizophreniaschizophrenia
Schizophrenia: Coronary Heart Disease Schizophrenia: Coronary Heart Disease (CHD)-Related Morbidity(CHD)-Related Morbidity
Compared with the general Compared with the general population, patients with population, patients with schizophreniaschizophrenia– Have a 20% shorter life expectancyHave a 20% shorter life expectancy– 2-fold higher risk of CHD 2-fold higher risk of CHD – Twice as likely to die of CHDTwice as likely to die of CHD– Major risk factors for CHD are more Major risk factors for CHD are more
commoncommon——smoking, smoking, hypercholesterolemia, hypertension, hypercholesterolemia, hypertension, obesity, and diabetesobesity, and diabetes
50% to 75% of patients with 50% to 75% of patients with schizophrenia have CHDschizophrenia have CHD
CHD=coronary heart disease. Hennekens et al. Am Heart J. 2005;150:1115-1121; Reader’s Digest Canada. http://www.readersdigest.ca/mag/2002/12/heart_attack.html. Accessed September 25, 2007.
Schizophrenia: Increased Smoking-Schizophrenia: Increased Smoking-Related MortalityRelated Mortality
aStandardized mortality ratio is the number of deaths observed divided by the number of deaths expected and multiplied by 100. An increased SMR is statistically significant when the lower confidence interval (95% CI) is 100 or more.Brown et al. Br J Psychiartry. 2000;177:212-217.
360
178
0
100
200
300
400
500
Nonsmokers Current Smokers
Sta
nd
ard
ized
Mo
rtal
ity
Sta
nd
ard
ized
Mo
rtal
ity
Rat
io (
SM
R)
Rat
io (
SM
R)aa
P=.05
Increased Incidence of Smoking in Increased Incidence of Smoking in Patients With Schizophrenia: TheoryPatients With Schizophrenia: Theory
Psychopathologic basisPsychopathologic basis– Schizophrenia is associated with a decrease in Schizophrenia is associated with a decrease in
dopaminergic activity in the prefrontal cortexdopaminergic activity in the prefrontal cortex– Nicotine may reduce negative symptoms in schizophrenia Nicotine may reduce negative symptoms in schizophrenia
by increasing dopamine release in the prefrontal cortexby increasing dopamine release in the prefrontal cortex
Pharmacotherapeutic basisPharmacotherapeutic basis– Antipsychotic medications block dopamine postsynaptic Antipsychotic medications block dopamine postsynaptic
receptors receptors – Schizophrenic patients may smoke to restore these Schizophrenic patients may smoke to restore these
blocked dopamine effectsblocked dopamine effects
Schilström et al. Int J Neuropsychopharmacol. 2003;6:1-11.
Smoking and Schizophrenia: Smoking and Schizophrenia: Patient Perceived BenefitsPatient Perceived Benefits
Cigarette smoking in Cigarette smoking in schizophrenia may be reinforcing schizophrenia may be reinforcing because it maybecause it may– Improve psychiatric symptomsImprove psychiatric symptoms– Improve cognitive functioningImprove cognitive functioning– Prevent worsening of these Prevent worsening of these
symptomssymptoms
Williams et al. Addict Behav. 2004;29:1067-1083; http://www.fotosearch.com/IDX015/558904. Accessed October 19, 2007.
25.6
37.1
0
10
20
30
40
50
Off Haloperidol On Haloperidol
Smoking: Effects of Antipsychotic Smoking: Effects of Antipsychotic TherapyTherapy
aCO is expired air carbon monoxide (CO). bNicotine levels were measured by gas chromatography.Patients were prospectively maintained free of antipsychotic medications for 4 to 7 days in hospital before baseline smoking measures were obtained.McEvoy et al. Psychopharmacology (Berl). 1995;119;124-126.
CO
(p
pm
)C
O (
pp
m)a
Nic
oti
ne
(ng
/mL
)N
ico
tin
e (n
g/m
L)bb
29.7
19.1
0
10
20
30
40
50
Off Haloperidol On Haloperidol
P=.008 P=.036
Smoking: Effects on Drug ClearanceSmoking: Effects on Drug Clearance
Clearance of psychotropic medications is significantly higher in smokers than in nonsmokers
Due to increased clearance, increased dosages often are required to achieve equivalent serum plasma levels
aClearance is directly proportional to the dosing rate divided by the steady-state plasma concentration.FPZ HCL=fluphenazine hydrochloride; FPZD=fluphenazine decanoate.Ereshefsky et al. Biol Psychiatry. 1985;20:329-352.
0
5
10
15
20
25
Oral Intramuscular
Nonsmokers Current Smokers
Cle
aran
ce (
L/m
in)
Cle
aran
ce (
L/m
in)aa
16.7216.72
9.999.99
3.163.16
7.377.37P<P<.005.005
FluphenazineFluphenazine
P<P<.005.005
Smoking Intervention and SchizophreniaSmoking Intervention and Schizophrenia
Underrecognition and undertreatment of nicotine Underrecognition and undertreatment of nicotine dependence in the schizophrenic population is commondependence in the schizophrenic population is common
Characteristics specific to the disease model and its Characteristics specific to the disease model and its hospital based treatment may have contributed to the hospital based treatment may have contributed to the onset and maintenance of nicotine dependence in onset and maintenance of nicotine dependence in individuals with schizophreniaindividuals with schizophrenia
Ziedonis et al. Curr Opin Psychiatry. 2003;16:305-315.
Smoking Cessation: Effects of Choice Smoking Cessation: Effects of Choice of Antipsychotic Therapyof Antipsychotic Therapy
Cessation rates are lower in schizophrenic smokers than in the general population
Compared with typical antipsychotic agents, atypical antipsychotic agents (in combination with the nicotine transdermal patch) significantly enhanced the rate of smoking cessation
Patients treated with atypical antipsychotics (n=18)
Patients treated with typical antipsychotics (n=27)
Per
cen
tag
e o
f P
atie
nts
P
erce
nta
ge
of
Pat
ien
ts
Wh
o Q
uit
Sm
oki
ng
Wh
o Q
uit
Sm
oki
ng
End Point 6-MonthFollow-up
George et al. Am J Psychiatry. 2000;157(11):1835-1842.
0
25
50
7.47.4
16.716.722.222.2
55.655.6
P<.01P<.01
P<.02P<.02
Summary: Smoking and SchizophreniaSummary: Smoking and Schizophrenia
Among patients with schizophrenia, smokingAmong patients with schizophrenia, smoking– Is pervasive, affecting 70% to 90% of patients Is pervasive, affecting 70% to 90% of patients – Is underdiagnosed and undertreated Is underdiagnosed and undertreated – Imposes a significant financial burdenImposes a significant financial burden– Contributes to increased incidence of coronary heart Contributes to increased incidence of coronary heart
disease (CHD) disease (CHD) – Increases metabolism of psychotropic medications Increases metabolism of psychotropic medications
requiring increased dosing requiring increased dosing – May improve psychiatric symptoms, cognitive functioning, May improve psychiatric symptoms, cognitive functioning,
and prevent exacerbation of symptomatologyand prevent exacerbation of symptomatology
Cessation rates are lower in patients with schizophrenia Cessation rates are lower in patients with schizophrenia than in the general populationthan in the general population
Smoking and Anxiety DisorderSmoking and Anxiety Disorder
1.9 1.73.1
6.7
0
2
4
6
8
10
12
14
Anxiety and Experimental SmokingAnxiety and Experimental Smoking
Anxiety and depressive symptoms, in the presence of peer smoking, Anxiety and depressive symptoms, in the presence of peer smoking, predict initiation of experimental smokingpredict initiation of experimental smoking
aThe relative likelihood of experiencing a particular event or the effect of an explanatory variable on the hazard or risk of an event. bClinical Interview Schedule (CIS) is a structured interview designed to assess symptoms of anxiety and depression in nonclinical populations. This scale generates scores (0 to 4) on 14 subscales of common psychiatric symptoms.Patton et al. Am J Public Health. 1998;88(10):1518-1522.
0-5 6-11 12-17 18+
Haz
ard
Rat
io (
95%
CI)
Haz
ard
Rat
io (
95%
CI)
aa
Levels of Psychiatric Morbidity (CIS Score)b
15.58
5.536.79
Adolescent Smoking and Anxiety Adolescent Smoking and Anxiety DisordersDisorders
aThe ratio of the odds of development of disease in exposed persons to the odds of development ofdisease in nonexposed person. bControlling for age, sex, difficult childhood temperament; alcohol and drug use, anxiety, and depressive disorders during adolescence; and parental smoking, education level, and psychopathology.Johnson et al. JAMA. 2000;284:(18):2348-2351.
Od
ds
Rat
io (
95%
CI)
Od
ds
Rat
io (
95%
CI)
a,b
a,b
Agoraphobia Generalized Anxiety Disorder
Panic Disorder
0
10
20
30
120
1.0
2.4
1.4
0
1
2
3
4
Nonsmokers Dependent Smokers NondependentSmokers
Nicotine Dependence and AnxietyNicotine Dependence and Anxiety Young adults with nicotine dependence have greater odds of Young adults with nicotine dependence have greater odds of
developing anxiety disorderdeveloping anxiety disorder
aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons. Adjusted for sex and other substance dependencies.Breslau et al. Behav Genet. 1995;25(2):95-101.
Od
ds
Rat
io (
95%
CI)
Od
ds
Rat
io (
95%
CI)
aa
Relationship Between Anxiety Disorder Relationship Between Anxiety Disorder and Smoking: Theoryand Smoking: Theory
Anxious individuals are at an Anxious individuals are at an elevated risk for nicotine elevated risk for nicotine addiction because of:addiction because of:– Social factorsSocial factors
• Peer pressure Peer pressure • Social fears Social fears • Facilitation of social Facilitation of social
interaction interaction – ““Calming” effects of smokingCalming” effects of smoking
Smoking contributes to the Smoking contributes to the development of anxiety disorders development of anxiety disorders because of:because of:– Impaired respiration Impaired respiration – Anxiogenic effects of nicotineAnxiogenic effects of nicotine
Adapted from: Johnson et al. JAMA. 2000;284(18):2348-2351; http://www.istockphoto.com/file_closeup/object/3721281_frustration_and_denial.php?id=3721281. Accessed October 11, 2007.
Summary: Smoking and Anxiety DisorderSummary: Smoking and Anxiety Disorder
Symptoms of anxiety and depression, in the presence of Symptoms of anxiety and depression, in the presence of peer smoking, predict initiation of experimental smokingpeer smoking, predict initiation of experimental smoking
Nicotine dependence during adolescence is associated Nicotine dependence during adolescence is associated with a higher odds ratio of generalized anxiety disorder with a higher odds ratio of generalized anxiety disorder (GAD) in early adulthood(GAD) in early adulthood
Multiple theories exist about the nature of the Multiple theories exist about the nature of the relationship between anxiety and smokingrelationship between anxiety and smoking
Smoking and Panic DisorderSmoking and Panic Disorder
Smoking and Panic DisorderSmoking and Panic Disorder
40% of panic disorder patients smoke40% of panic disorder patients smoke
Effective substance for self-medication of anxietyEffective substance for self-medication of anxiety
Anxiogenic effect of nicotine is hypothesized to be more Anxiogenic effect of nicotine is hypothesized to be more important in the etiology of panic disorderimportant in the etiology of panic disorder
Positive relationship between smoking and panic Positive relationship between smoking and panic disorderdisorder
Pohl et al. Psychiatry Res. 1992;43:253-262; Amering et al. Compr Psychiatry. 1999;40(1):35-38; Breslau et al. Arch Gen Psychiatry. 1999;56:1141-1147; Johnson et al. JAMA. 2000;284(18):2348-2351; Isensee. Arch Gen Psychiatry. 2003;60:692-700; Lasser et al. JAMA. 2000;284(20):2606-2610.
3.33.6
2.9
1.0
0
3
6
9
12
Nicotine Dependence: Risk of Panic Nicotine Dependence: Risk of Panic DisorderDisorder
aThe ratio of the odds of development of disease in exposed persons to the odds of development of disease in nonexposed persons.Isensee et al. Arch Gen Psychiatry. 2003;60:692-700.
Od
ds
Rat
io (
95%
CI)
Od
ds
Rat
io (
95%
CI)
aa
New Onset of New Onset of Panic Attacks Panic Attacks
With Prior With Prior Regular SmokingRegular Smoking
New Onset of Panic New Onset of Panic Attacks With Attacks With
Nicotine Nicotine DependenceDependence
Onset of Panic Onset of Panic Disorder With Disorder With
Nicotine Nicotine DependenceDependence
NonsmokersNonsmokers
PP<.05<.05
PP<.05<.05
PP<.05<.05
Panic Disorder: Increased Rates Panic Disorder: Increased Rates of Cessationof Cessation
55
1728
15
56
28
0
10
20
30
40
50
60
70
aValue for general population outside CI. bCensus 1991.Amering et al. Compr Psychiatry. 1999;40(1):35-38.
Sm
oke
rs (
%)
(95%
CI)
Sm
oke
rs (
%)
(95%
CI)
Panic Disorder Patients at Time of Assessment
(n=102)
General Population, Aged >15 1991 Census data
(N=5,329,300)
Ex-smokers Current Smokers Never Smokers
a
a
a
Summary: Smoking and Panic DisorderSummary: Smoking and Panic Disorder
Both prior regular smoking and nicotine dependence are Both prior regular smoking and nicotine dependence are associated with risk of anxiety disorders in adolescence associated with risk of anxiety disorders in adolescence and early adulthoodand early adulthood
Smoking-cessation rates are higher in patients with panic Smoking-cessation rates are higher in patients with panic disorder than in the general populationdisorder than in the general population
ConclusionsConclusions Addiction is a multistep process involving multiple neurocircuitsAddiction is a multistep process involving multiple neurocircuits
Nicotine dependence is an addictive disorderNicotine dependence is an addictive disorder
Binding of nicotine to the Binding of nicotine to the 442 receptors in the ventral tegmental area 2 receptors in the ventral tegmental area (VTA) results in the dopaminergically mediated physical and (VTA) results in the dopaminergically mediated physical and psychological rewards of smoking psychological rewards of smoking
Smoking is highly prevalent in the psychiatric populationSmoking is highly prevalent in the psychiatric population
Compared with the general population, schizophrenic and depressed Compared with the general population, schizophrenic and depressed smokers are less likely to successfully quit smoking, although smokers smokers are less likely to successfully quit smoking, although smokers with panic disorder have higher cessation rateswith panic disorder have higher cessation rates
Smokers with psychiatric disorders may smoke to ameliorate their Smokers with psychiatric disorders may smoke to ameliorate their pathologic symptomatologypathologic symptomatology
There appears to be a distinct association between smoking and There appears to be a distinct association between smoking and suicidesuicide
Environmental/social stimuli associated with smoking play a role in Environmental/social stimuli associated with smoking play a role in reinforcing nicotine dependencereinforcing nicotine dependence