Table.

Recommended Treatments for Tobacco Dependence and the Evidence Base for Use in Smokers with Mental Illness.^*

Treatment Strategy	Findings in Smokers with Mental Illness
Clinician advice to quit and referral	In one trial in clinically depressed smokers, yielded abstinence rate of 19% at 18 months of follow-up.1
Individual cessation counseling	At 18 months of follow-up, individual counseling with access to cessation pharmacotherapy achieved abstinence in 18% of smokers with PTSD3 and 25% of those with depression.1
Group cessation counseling	Group counseling plus nicotine replacement achieved 19 to 21% abstinence at 12 months of follow-up in outpatients with serious mental illness; tailoring content for smokers with schizophrenia was equally effective.
Quit-lines	The nearly 25% of callers to the California quit-line who had major depression were significantly less likely than nondepressed callers to have quit smoking at 2 months of follow-up.
Nicotine replacement: patch, gum, lozenge, inhaler, nasal spray	One trial found nicotine gum particularly helpful among depressed (as compared with nondepressed) smokers (36% abstinence at 3 months). In acute care settings, nicotine replacement reduced agitation in smokers with schizophrenia and was associated with lower rates of leaving inpatient psychiatric settings against medical advice. Ex tended use of a nicotine patch reduced relapse risk among smokers with schizophrenia. A case series documented that nicotine nasal spray was used appropriately by smokers with schizophrenia and supported cessation.
Bupropion	An effective cessation aid in smokers with or without current or past depression. A meta-analysis of 7 trials in 260 smokers with schizophrenia showed significant effects at 6 months of follow-up.4 According to a case study, two smokers with bipolar disorder quit smoking with no adverse effects on mood.
Varenicline	Three case series involving medically stable outpatients with schizophrenia reported significant smoking reduction, 8-to-75% quit rates, improvements on some cognitive tests, and no serious adverse effects; individual case reports reveal mixed effects in smokers with schizophrenia or bipolar disorder. Three randomized, controlled trials in smokers with schizophrenia or depression are in process.
Nortriptyline	Demonstrated efficacy in the general population and among smokers with a history of depression; no data on smokers with current mental illness.
Clonidine	Demonstrated efficacy in the general population; no data on smokers with mental illness.

^*Information on recommended treatments for tobacco dependence is from Fiore et al.⁵ Bupropion and varenicline include an FDA-mandated black-box warning highlighting the risk of serious neuropsychiatric symptoms, including changes in behavior, hostility, agitation, depressed mood, suicidal thoughts and behavior, and attempted suicide. Nortriptyline and clonidine are second-line cessation pharmacotherapies that have been identified as efficacious in the general population but are not FDA- approved. PTSD denotes post-traumatic stress disorder.