For Smokers With Schizophrenia: The JUUL in the Crown

 

The vast majority of people with mental illness also smoke – a lot.  In fact smoking, which delivers to tortured brains the soothing drug nicotine, is considered by many sufferers, and their doctors, as not optional.

More than 60 percent of schizophrenia patients are current smokers (here), but hope may be found in a small open-label Italian clinical trial, reported by Pasquale Caponnetto at the University of Catania and his colleagues.

Caponnetto et al. recruited 40 people with schizophrenia who did not intend to reduce or quit smoking; they were given JUUL e-cigarettes and pods for 12 weeks.  Caponnetto found that 16 subjects had quit smoking over that period, and 21 others had reduced their cigarette consumption from a median of 25 before the trial, to 10.  At the final six-month follow-up visit, when all participants had been purchasing their own tobacco products for three months, 14 had quit smoking.

This study demonstrates that e-cigarettes can be an aid to cessation or reduced consumption for people with schizophrenia who don’t intend to give cigarettes up.  There is one caveat.

Caponnetto used full-strength JUUL pods – also sold in the U.S. – which contain 59 milligrams of nicotine per milliliter of e-liquid.  The researchers probably obtained special permission from regulatory authorities as the European Union limits e-liquids to only 20 mg of nicotine per ml.  It is likely that smokers with mental illness require higher doses of nicotine in cigarette substitutes.

I am reminded of a short article published in the American Journal of Psychiatry in 2005 (reference here):

“Ms. A, a 52-year-old woman with schizoaffective disorder, bipolar type, started smoking shortly after her first psychotic episode at age 19 and, on average, smoked about 1½ packs per day for 33 years. She had attempted to quit using pharmacotherapy, nicotine gum, or patches in combination with cessation classes. Both gum and patch treatments were ineffective since they did not control her craving for cigarettes.

“Her motivation to quit was strong because of the sequelae of smoking: bronchitis, isolation from others, and destabilization of her psychiatric illness from frequently awakening to smoke. Her brother with a bipolar disorder had experienced severe burns over most of his body and died secondary to a fire caused by his smoking. For her, smoking had become a constant reminder of his suffering, which led to nightmares and further isolation. She was afraid to jeopardize the health and safety of others.

“One year ago, she was cross-titrated over a 1-week period to oral pouches. Since that time, she has not resumed smoking, and her psychiatric and medical symptoms have stabilized. Before her cessation of smoking, she lived an isolated existence. Now she resides with and cares for her parents. For Ms. A, ceasing to smoke was a life-changing event.”

Doctors in 2005 successfully switched a patient with severe mental problems from cigarettes to smokeless tobacco, citing two of my studies (here and here) as the scientific basis for their humane and “life-changing” guidance.   

Now, doctors in Italy have produced life changing evidence that patients with schizophrenia can successfully switch to JUUL.

 

 

 

 

Smoking May Harm Mental Health

Research has documented a strong link between smoking and various mental health disorders, including anxiety, depression, schizophrenia and bipolar disorder.  The CDC advises that about 20% of American adults had some form of mental illness in 2009-2011, and the smoking rate for that group was 36%, in contrast to 21% for all others (here).

There is certainly an association, but there are four distinct possibilities with respect to causality:

·       Mental health problems cause people to smoke.

·       Smoking causes mental health problems.

·       Both pathways exist.

·       Neither pathway exists.

My economist colleague Dr. Nantaporn Plurphanswat is the lead author of an innovative analysis that identifies a potential causal pathway for mental illness and smoking; the work appears in the American Journal of Health Behavior (abstract here).  Our co-author is University of Illinois professor Dr. Robert Kaestner.  We used data from people in almost all states participating in the federal Behavioral Risk Factor Surveillance System (BRFSS) from 2000 to 2010.  BRFSS collected information on smoking and asked participants “…for how many days during the past 30 days was your mental health [which includes stress, depression, and problems with emotions] not good?”

Recognizing that traditional approaches cannot identify a causal pathway between smoking and mental illness, Drs. Plurphanswat and Kaestner employed an instrumental variable approach, in which variation in smoking at the state level is strongly associated with cigarette excise taxes, but the excise taxes are completely unrelated to outcomes like mental health.  The IV analysis provides information on whether smoking leads to mental health problems, or vice versa.

Our results indicate that smoking may harm mental health: it is significantly associated with 14 or more days of poor mental health.  Most of the effect due to smoking is from large increases in the number of mentally unhealthy days and not by small increases among many smokers. 

The BRFSS data cannot tell us whether smoking is a form of self-medication practiced by those who suffer from specific mental health disorders.  However, our analysis confirms that smoking may contribute to anxiety, depression and emotional distress.  Thus, policies that reduce smoking may have a positive spill-over effect in improving mental health.