There’s no better way to enhance your patients’ health than to help the smokers among them shed their addiction. The proportion of Canadians who smoke has dropped significantly — most of those for whom cessation is relatively easy have quit. Those who remain smokers are arguably “hardened smokers” whose addiction is particularly tenacious, perhaps reflecting a genomic/metabolic predisposition.

Smoking and mental health

It’s increasingly recognized that people who remain smokers have a significantly elevated level of psychiatric co-morbidities. It’s been calculated that almost 44% of all cigarettes consumed in North America are smoked by those with co-existing mental illnesses. Patients with mental illness have dramatically reduced life expectancies — largely due to tobacco-related diseases. Many physicians are unmindful of these associations. Mental illness doesn’t kill most psychiatric patients… tobacco diseases do, very frequently.

Some smokers derive partial relief of psychiatric symptoms by smoking. Tobacco smoke contains beta-carbolenes, which act as monoamine oxidase inhibitors. Monoamine oxidase levels are thus reduced in smokers… with a possible lessening of symptoms of depression. Not surprisingly therefore, the emergence of symptoms of depression may noit uncommonly accompany smoking cessation, harming chances of success. It helps to ask patients contemplating cessation about any history of previous depression or other psychiatric illness, to be alert for symptoms, and to be prepared to treat them.

Coffee and a smoke

The relationship between caffeine metabolism and smoking is largely unknown to most practitioners. The polycyclic hydrocarbons in tobacco smoke speed up the metabolism of many medications… and of caffeine. Stop smoking and caffeine levels, given constant caffeine intake, will triple! The resulting ‘caffeineism’ is usually misinterpreted as anxiety or withdrawal. Advise smokers attempting cessation to reduce caffeine intake.

Patch up your patients

When we manage hypertension we’re comfortable, very comfortable, with the titration and combination of medications. Increasingly, it’s recognized that best practice smoking cessation involves the same approach. The standard doses of nicotine replacement therapies (NRT) won’t meet the nicotine needs of almost 65% of smokers (that’s why patients complain that “the patch doesn’t work for me”). Titrating NRT doses to a point at which the patient no longer experiences craving can boost chances of success. Just as we wouldn’t stop treating hypertension or hyperlipidemia after 12 weeks, consider that NRT might be continued for as long as it takes.