Are there any effective interventions to help individuals with schizophrenia to quit or to reduce smoking?

Tsoi DT, Porwal M, Webster AC

Published Online:

March 16, 2011

People with schizophrenia are, very often, heavy smokers. It is uncertain whether treatments that have been shown to help other groups of people to quit smoking are also effective for people with schizophrenia. In this review, we found that bupropion (an antidepressant medication previously shown to be effective for smoking cessation) helps patients with schizophrenia to quit or to reduce smoking. The effect was clear at the end of the treatment and it may also be maintained after six months. Patients who used bupropion in the trials did not experience any major adverse effect and their mental state was stable during the treatment. Smokers with schizophrenia who receive money as a reward for quitting may have a higher rate of stopping smoking whilst they get payments. However, there is no evidence that they will remain abstinent after the reward stops. There was too little evidence to show whether other treatments like nicotine replacement therapy and psychosocial interventions are helpful.

Abstract (click to read)

Background:

Patients with schizophrenia smoke more heavily than the general population and this contributes to their higher morbidity and mortality from smoking-related illnesses. It remains unclear what interventions can help them to quit or reduce smoking.

Objectives:

To evaluate the benefits and harms of different treatments for nicotine dependence in schizophrenia.

Search strategy:

We searched the Cochrane Tobacco Addiction Group Specialized Register and electronic databases including MEDLINE, EMBASE and PsycINFO from inception to April 2010.

Selection criteria:

We included randomized trials for smoking cessation or reduction, comparing any pharmacological or non-pharmacological intervention with placebo or with another therapeutic control in adult smokers with schizophrenia or schizoaffective disorder.

Data collection and analysis:

Two reviewers independently assessed the eligibility and quality of trials and extracted data. Outcome measures included smoking abstinence, reduction in the amount smoked and any change in mental state. We extracted abstinence and reduction data at the end of treatment and at least six months after the intervention. We used the most rigorous definition of abstinence or reduction and biochemically validated data where available. Any reported adverse events were noted. Where appropriate, we pooled data using a random effects model.

Main results:

We included 21 trials (11 trials of smoking cessation; four trials of smoking reduction; one trial for relapse prevention; five trials reported smoking outcomes for interventions aimed at other purposes). Seven trials compared bupropion with placebo; meta-analysis showed that smoking cessation rates after bupropion were significantly higher than placebo at the end of treatment (seven trials, N=340; risk ratio [RR] 2.84; 95% confidence interval [CI] 1.61 to 4.99) and after six months (five trials, N=214, RR 2.78; 95% CI 1.02 to 7.58). Expired carbon monoxide (CO) level and the number of cigarettes smoked daily were significantly lower with bupropion at the end of therapy but not after six months. There were no significant differences in positive, negative and depressive symptoms between bupropion and placebo group. There was no report of major adverse event such as seizures with bupropion.

Contingent reinforcement (CR) with money may increase smoking abstinence rates and reduce the level of smoking in patients with schizophrenia. However, it is uncertain whether these benefits are maintained in the longer term. There was no evidence of benefit for the few trials of other pharmacological therapies (including nicotine replacement therapy (NRT)) and psychosocial interventions in helping smokers with schizophrenia to quit or reduce smoking.

Authors' conclusions:

Bupropion increases smoking abstinence rates in smokers with schizophrenia, without jeopardising their mental state. Bupropion may also reduce the amount these patients smoke. CR may help this group of patients to quit and reduce smoking. We failed to find convincing evidence that other interventions have a beneficial effect on smoking behaviour in schizophrenia.

This record should be cited as:

Tsoi DT, Porwal M, Webster AC. Interventions for smoking cessation and reduction in individuals with schizophrenia. Cochrane Database of Systematic Reviews 2010, Issue 6. Art. No.: CD007253. DOI: 10.1002/14651858.CD007253.pub2

Assessed as up to date:

April 19, 2010

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Primary Review Group:

Tobacco Addiction Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective are interventions for smoking cessation in schizophrenia?

Bottom line:

Compared with placebo, bupropion increased smoking abstinence rates in smokers with schizophrenia for up to six months (NNT* 17), without jeopardising their mental state. Expired carbon monoxide (CO) level and the number of cigarettes smoked daily were significantly lower with bupropion at the end of therapy but not after six months. There were no significant differences in positive, negative and depressive symptoms between bupropion and placebo groups. There was no report of any major adverse event, such as seizures, with bupropion use. One study showed contingent reinforcement (CR) with money increased smoking abstinence rates and reduced the level of smoking. However, there was no evidence CR produced sustained results for these outcomes in the longer term. * NNT = number needed to treat to benefit one individual.

Caveat:

The strength of the evidence for bupropion was relatively weak with wide confidence intervals, especially for longer-term benefit, because of the small number of participants. There was no evidence of benefit for the few trials of other pharmacological therapies (including nicotine replacement therapy) and psychosocial interventions, in helping smokers with schizophrenia to quit or reduce smoking.

Context:

People with schizophrenia smoke more heavily than the general population and this contributes to their higher morbidity and mortality from smoking-related illnesses.

Cochrane Systematic Review:

Tsoi DT et al. Interventions for smoking cessation and reduction in individuals with schizophrenia. Cochrane Reviews 2010, Issue 6. Article No. CD007253. DOI: 10.1002/14651858. CD007253.pub2. This review contains 21 studies involving 1289 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Lungs & airways > Smoking cessation > Interventions in specific groups

Tobacco, drugs, & alcohol dependence > Tobacco > Interventions in specific groups

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Are there any effective interventions to help individuals with schizophrenia to quit or to reduce smoking?

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