2006). There was a dose–response relationship between abstinence and attendance at the treatment sessions.

An additional, potentially unexpected benefit of reducing or eliminating tobacco use by patients with mental illness is lowering of psychotropic medication dosages. Patients with serious mental illness, such as schizophrenia or bipolar disorder, are commonly given antipsychotic medications, such as olanzapine or clozapine. Smokers who receive those medications may need about twice the dosage of nonsmokers, because of the effect of the polycyclic aromatic hydrocarbons in tobacco smoke on medication metabolism (Desai et al., 2001). Other medications that are affected similarly include haloperidol and fluphenazine (Desai et al., 2001; Workgroup on Substance Use Disorders, 2006). Cigarette smoking may also increase the clearance of benzodiazepines (Smith et al., 1983). Careful monitoring of the side effects of psychiatric medications during changes in tobacco use is necessary, particularly during the early abstinence period (VA/DoD, 2004). Health-care providers should be actively involved in working with patients to adjust medications and to inquire about side effects. Tobacco users with mental illness may need to be treated for a longer period and with more intensive treatments than nonusers (Collie et al. 2006).

In the section below, the committee assesses the evidence on tobacco-cessation interventions for specific psychiatric disorders that may be seen in military personnel returning from Iraq and Afghanistan and in veterans from those and earlier conflicts: PTSD, major depressive disorder (MDD), alcohol abuse and dependence, and schizophrenia.

Posttraumatic Stress Disorder

In a review by Fu et al. (2007), PTSD was strongly associated with tobacco use and nicotine dependence; many studies reported smoking rates of over 50% in those with the disorder. Although several observational studies have shown that smokers with PTSD are less inclined to quit smoking than smokers without PTSD or with other psychiatric disorders, several clinical studies have indicated that smokers with PTSD or other mental disorders respond to tobacco-cessation treatment at levels nearly equivalent to those in smokers without mental disorders (Fu et al., 2007).

For tobacco users with PTSD, there appears to be greater abstinence from tobacco use when cessation interventions are integrated into standard mental health care. In one study, 107 veterans with PTSD who smoked were encouraged to make multiple attempts to quit (that is, repeated treatment) during a 6-month treatment period. The 9-month, 7-day point-prevalence abstinence rate was 18% in the integrated-care



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