It’s a long game: Working with my patient with schizophrenia to reduce smoking

Let me tell you about Janie, a 47 year old woman who lives with her husband and her dog Queenie. Janie is my patient. It’s not her real name.
 
Janie lives with schizophrenia. While this is well-controlled, with no psychotic episodes for the last 10 years, she fears a relapse of symptoms. Both she and her husband smoke.
 
Daily life is a constant struggle for Janie. A background of severe childhood trauma has left her with a high level of anxiety, she’s on a disability support pension and has a history of alcohol dependence, though she is currently abstinent.
 
‘I fear my ‘schizo’ will come back, I feel like I’m always waiting for it to come back and destroy my life,’ Janie once told me. Janie is also a highly dependent smoker. She smokes 30 cigarettes a day, with her first soon after waking. She’s tried very hard to stop without success.
 
Two thirds of people who smoke tobacco will die from smoking related illness. The good news is, if people give up, their risk of mortality drops over time. But the problem is that, like Janie, many patients find it very tricky to stop smoking. In fact, 60-70% of people living with schizophrenia smoke tobacco and are likely to be highly dependent, which means they need more intense support and treatment to successfully quit.
 
When I raise the subject Janie shakes her head. ‘No doc, don’t make me do this. It’s too hard, my mental health will get worse and I won’t succeed anyway.’  Even so, I raise the subject gently most times I see her.
 
Six months ago I changed tack.   
 
‘Janie,’ I said. ‘Did you know the evidence says that your mental health actually improves after you give up smoking? And that tobacco stops your meds working so well? That means we might be able to drop the dose of your [antipsychotic] medication.’
 
That clinched it. Janie agreed to give it a go, though she remained somewhat sceptical.
 
The evidence is that there are two good medications that assist quitting: combination nicotine replacement therapy (NRT) and Varenicline. Either would be an option for Janie. As well as medication, highly dependent smokers benefit from additional support, so it can help to assist them to engage with family, Quitline, online options and others involved in their care such as mental health case manager.

I discussed the process of quitting. Janie was very surprised when I suggested that she start the medication for smoking cessation while still smoking.  She laughed at me. ‘You’re crazy doc, but I’m willing to give it a go,’ she said.
 
Knowing Janie was very worried about how she’d go with the plan, I followed her up regularly with the help of our nurse and also spoke to her case manager at the local mental health team.  She started the treatment and a week later reported that although she hadn’t fully stopped, she’d managed to cut down the number of cigarettes. Even more importantly, she now didn’t have her first cigarette of the day until three hours after waking. Her mental health was OK, and she had no problems with the medication.  
 
I’d be lying if I said it all went smoothly from there – there were ups and downs. But I’m encouraged. Janie has been able to reduce her smoking without it being too distressing.  Even better, two months ago she stopped altogether.  
 
I’m still holding my breath to see how she goes. It is likely she’ll relapse at some point but I’m taking a long term view. Every cigarette she doesn’t smoke is doing her good. Plus, now she has the experience of being able to manage this, with lots of support from us. I have no doubt that longer term, she’ll succeed.
 
Last time I saw Janie, she said ‘Doc, you know who’s happiest about me stopping smoking?’ I shook my head.  ‘My dog Queenie. I don’t get so breathless now walking to the park and she does love a walk.’
 
With more walking and less smoking, I think maybe we’ll be able to get the weight down too. But that’s for another day.

schizophrenia smoking tobacco