Interventions for smoking cessation and reduction in individuals with schizophrenia

  • Review
  • Intervention

Authors


Abstract

Background

Individuals 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 to reduce smoking.

Objectives

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

Search methods

We searched electronic databases including MEDLINE, EMBASE and PsycINFO from inception to October 2012, and the Cochrane Tobacco Addiction Group Specialized Register in November 2012.

Selection criteria

We included randomised 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, as well as 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. We noted any reported adverse events. Where appropriate, we pooled data using a random-effects model.

Main results

We included 34 trials (16 trials of cessation; nine trials of reduction; one trial of relapse prevention; eight trials that reported smoking outcomes for interventions aimed at other purposes). Seven trials compared bupropion with placebo; meta-analysis showed that cessation rates after bupropion were significantly higher than placebo at the end of treatment (seven trials, N = 340; risk ratio [RR] 3.03; 95% confidence interval [CI] 1.69 to 5.42) and after six months (five trials, N = 214, RR 2.78; 95% CI 1.02 to 7.58). There were no significant differences in positive, negative and depressive symptoms between bupropion and placebo groups. There were no reports of major adverse events such as seizures with bupropion.

Smoking cessation rates after varenicline were significantly higher than placebo, at the end of treatment (2 trials, N = 137; RR 4.74, 95% CI 1.34 to 16.71). Only one trial reported follow-up at six months and the CIs were too wide to provide evidence of a sustained effect (one trial, N = 128, RR 5.06, 95% CI 0.67 to 38.24). There were no significant differences in psychiatric symptoms between the varenicline and placebo groups. Nevertheless, there were reports of suicidal ideation and behaviours from two people on varenicline.

Two studies reported that 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 can be 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 jeopardizing their mental state. Varenicline may also improve smoking cessation rates in schizophrenia, but its possible psychiatric adverse effects cannot be ruled out. CR may help this group of patients to quit and reduce smoking in the short term. We failed to find convincing evidence that other interventions have a beneficial effect on smoking in schizophrenia.

Plain language summary

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

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 analysed studies which investigated a wide variety of interventions. Our results suggested that bupropion (an antidepressant medication previously shown to be effective for smoking cessation) helps patients with schizophrenia to quit 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. Another medication, varenicline (a nicotine partial agonist which has been shown to be an effective intervention for smoking cessation in smokers without schizophrenia), also helps individuals with schizophrenia to quit smoking at the end of the treatment. However, this evidence is only based on two studies. We did not have sufficient direct evidence to know whether the benefit of varenicline is maintained for six months or more. In addition, there has been ongoing concern of potential psychiatric adverse events including suicidal ideas and behaviour among smokers who use varenicline. We found that two patients, among 144 who used varenicline, had either suicidal ideas or behaviour. 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.

Laički sažetak

Postoje li učinkoviti postupci koji bi pomogli oboljelima od shizofrenije u prestanku ili smanjenju pušenja?

Osobe oboljele od shizofrenije su često teški pušači. Nije utvrđeno pomažu li terapije koje su pokazale učinkovitost kod drugih skupina i oboljelima od shizofrenije. U ovom Cochrane sustavnom pregledu analizirane su studije koje su istraživale različite intervencije. Rezultati upućuju da bupropion (lijek antidepresiv koji se pokazao učinkovit za prestanak pušenja) pomaže pacijentima sa shizofrenijom u prestanku pušenja. Učinak je bio jasan na kraju terapije i mogao se održavati i nakon šest mjeseci. Pacijenti koji su koristili bupropion nisu iskusili nikakve značajnije nuspojave i njihovo mentalno stanje je bilo stabilno tijekom terapije. Drugi lijek, vareniklin (parcijalni agonist nikotinskih receptora koji se pokazao učinkovit u prestanku pušenja za pojedince koji nisu oboljeli od shizofrenije), isto pomaže pojedincima oboljelim od shizofrenije u prestanku pušenja na završetku terapije. Dokazi su temeljeni na samo dvije studije. Nije pronađeno dovoljno izravnih dokaza kako bi se znalo je li učinak vareniklina održan šest mjeseci ili više. Dodatno, postoji bojazan da bi se mogle razviti psihijatrijske nuspojave, uključujući samoubilačke (suicidalne) misli i ponašanje među pušačima koji koriste vareniklin. Pronađeno je da su dva pacijenta, od 144 koji su koristili vareniklin, pokazivali suicidalne misli ili ponašanje. Pušači sa shizofrenijom koji su dobivali novac kao nagradu za prestanak pušenja mogu imati veće stope prestanka pušenja dok primaju novac. Međutim, ne postoje dokazi da će nastaviti apstinirati nakon prestanka nagrađivanja. Bilo je premalo dokaza koji pokazuju pomaže li toj skupini pacijenata u prestanku ili smanjenju pušenja neka druga terapija poput terapije nadoknade nikotina ili psihosocijalnih intervencija.

Bilješke prijevoda

Hrvatski Cochrane
Preveo: Adam Galkovski
Ovaj sažetak preveden je u okviru volonterskog projekta prevođenja Cochrane sažetaka. Uključite se u projekt i pomozite nam u prevođenju brojnih preostalih Cochrane sažetaka koji su još uvijek dostupni samo na engleskom jeziku. Kontakt: cochrane_croatia@mefst.hr

Streszczenie prostym językiem

Czy istnieją skuteczne interwencje, które mogą pomóc osobom chorującym na schizofrenię rzucić lub ograniczyć palenie?

Osoby chorujące na schizofrenię bardzo często palą nałogowo papierosy. Nie jest pewne, czy terapie antynikotynowe o udowodnionej skuteczności w innych grupach osób, są także skuteczne wśród osób chorych na schizofrenię. W niniejszym przeglądzie dokonano analizy badań oceniających szeroki zakres interwencji. Nasze wyniki sugerowały, że bupropion (lek przeciwdepresyjny, którego skuteczność w terapii antynikotynowej już wykazano) pomaga pacjentom ze schizofrenią rzucić palenie. Efekt zaznaczył się wyraźnie pod koniec leczenia i może się także utrzymywać po sześciu miesiącach. Pacjenci, którzy stosowali bupropion podczas badań, nie doświadczali żadnych poważnych działań niepożądanych, a ich stan psychiczny był stabilny podczas leczenia. Inny lek, wareniklina, (częściowy agonista nikotyny, o udowodnionej skuteczności w terapii antynikotynowej u osób bez schizofrenii), pomaga również osobom ze schizofrenią rzucić palenie pod koniec leczenia. Dane te są jednak oparte tylko na dwóch badaniach. Nie dysponowano wystarczającymi danymi bezpośrednimi, aby stwierdzić czy korzyść ze stosowania warenikliny utrzymuje się przez sześć lub więcej miesięcy. Dodatkowo, cały czas obecne były obawy związane ze zdarzeniami niepożądanymi, w tym myślami i zachowaniami samobójczymi, u palaczy wykorzystujących wareniklinę. Stwierdzono, że u dwóch pacjentów, spośród 144 zażywających wareniklinę, występowały myśli lub zachowania samobójcze. Palacze ze schizofrenią, którzy otrzymywali pieniądze jako nagrodę za zerwanie z nałogiem, częściej rzucali palenie, gdy dostawali zapłatę. Nie ma jednak danych wskazujących, to, że pozostaliby w abstynencji po tym, jak przestaną otrzymywać nagrodę. Dysponowano zbyt niewielką ilością danych, aby stwierdzić, czy inne leczenie jak nikotynowa terapia zastępcza i interwencje psychospołeczne są pomocne.

Uwagi do tłumaczenia

Tłumaczenie Bartłomiej Matulewicz Redakcja Katarzyna Mistarz

Ancillary