Tobacco and health care
Online posting: May 23, 1997
Published in print: July 15, 1997 (CMAJ 1997;157:133)
Re: "Tobacco and health" [CMA policy summary]. Can Med
Assoc J 1997;156:240A-C [full text / texte complet].
See response by: D.J. MacKenzie
As a psychiatrist/addictionist, I find it distressing that the
most intense opposition to smoking bans and to the treatment of
nicotine dependence seems to be found in addiction-treatment
facilities and psychiatric hospitals.
There is no scientific justification for this resistance.[1]
According to Dr. Richard Hurt, smoking-related illness is by far
the leading cause of death in recovering alcoholics; and it is
presumably the foremost cause of death among other addicts and
patients receiving psychiatric care as well.
According to Dr. Terry Rustin, in US treatment centres addicts
who give up tobacco at the outset of treatment complete treatment
at higher rates and have improved rates and longer periods
without relapse after treatment. The prelimary results seem so
promising that it is difficult to justify to third-party payers
not treating nicotine dependence concurrently with other
addictions.
Fears that patients receiving psychiatric care will experience
a relapse of depression upon smoking cessation may be
exaggerated.[2,3] In fact, smoking tobacco significantly alters
the P-450 enzyme system, necessitating higher doses of
antidepressants and tranquillizers. Patients with psychiatric
problems who stop smoking may need to be monitored for side
effects and to have dosages lowered appropriately. For those who
exhibit depression on smoking cessation, adequate antidepressant
therapy and smoking-cessation support is the treatment of choice,
not physician-approved tobacco use.
Many patients start smoking during stays at addiction and
psychiatric treatment facilities. Those who smoke before
admission tend to increase the amount they smoke during stays.
Tobacco addiction, denial, rationalization and apathy about
nicotine dependence are endemic among treatment staff.
Why were patients with other addictions (alcohol, marijuana,
cocaine, amphetamines, opiates or prescription drugs), and
psychiatric inpatients -- populations with an 80% or more
prevalence of nicotine dependence -- not included as high-risk
populations in the CMA policy summary on tobacco and health?
These groups are glaring and unfortunate exclusions.
Reid Finlayson, MD
Homewood Addiction Division
Homewood Health Centre
Guelph, Ont.
reidf@wat.hookup.net
References
- American Psychiatric Association position statement on
nicotine dependence. Am J Psychiatry 1995;152(3):481-2.
- Practice guidelines for the treatment of patients with
nicotine dependence. Am J Psychiatry 1996;153(4 suppl).
- Dalack GW, Glassman AH. A clinical approach to help
psychiatric patients with smoking cessation. Psychiatr Q
1992;63(1):27-39.
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