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Meta-Analysis
. 2013 Feb 28;2013(2):CD007253.
doi: 10.1002/14651858.CD007253.pub3.

Interventions for smoking cessation and reduction in individuals with schizophrenia

Daniel T Tsoi  1 , Mamta Porwal, Angela C Webster
Affiliations
Meta-Analysis

Interventions for smoking cessation and reduction in individuals with schizophrenia

Daniel T Tsoi et al. Cochrane Database Syst Rev. .

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.

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Conflict of interest statement

None known.

Figures

1
1
Summary of the process of identifying randomised trials for inclusion
2
2
Bupropion versus placebo: Abstinence at 6‐month follow‐up (primary outcome)
3
3
Bupropion versus placebo: Mental state outcomes
4
4
Varenicline versus placebo: Abstinence at the end of treatment (secondary outcome)
1.1
1.1. Analysis
Comparison 1 Bupropion versus placebo, Outcome 1 Abstinence at 6‐month follow‐up (primary outcome).
1.2
1.2. Analysis
Comparison 1 Bupropion versus placebo, Outcome 2 Abstinence at end of treatment (secondary outcome).
1.3
1.3. Analysis
Comparison 1 Bupropion versus placebo, Outcome 3 Mental state outcomes ‐ abstinence studies.
1.4
1.4. Analysis
Comparison 1 Bupropion versus placebo, Outcome 4 Reduction ‐ Expired CO level at the end of treatment (secondary outcome) ‐ abstinence studies.
1.5
1.5. Analysis
Comparison 1 Bupropion versus placebo, Outcome 5 Reduction ‐ Expired CO level at 6‐month follow‐up (secondary outcome) ‐ abstinence studies.
1.6
1.6. Analysis
Comparison 1 Bupropion versus placebo, Outcome 6 Reduction ‐ Change in number of CPD from baseline at the end of treatment (secondary outcome) ‐ abstinence studies.
1.7
1.7. Analysis
Comparison 1 Bupropion versus placebo, Outcome 7 Reduction ‐ Change in number of CPD from baseline at 6‐month follow‐up (secondary outcome) ‐ abstinence studies.
1.8
1.8. Analysis
Comparison 1 Bupropion versus placebo, Outcome 8 Reduction ‐ Change in number of CPD from baseline at the end of treatment (secondary outcome) ‐ reduction studies.
2.1
2.1. Analysis
Comparison 2 Varenicline versus placebo, Outcome 1 Abstinence at 6‐month follow‐up (primary outcome).
2.2
2.2. Analysis
Comparison 2 Varenicline versus placebo, Outcome 2 Abstinence at end of treatment (secondary outcome).
See this image and copyright information in PMC

Update of

References

References to studies included in this review

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*George 2002 {published data only}
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*George 2008 {published data only}
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*Weiner 2012 {published data only}
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*Williams 2007 {published data only}
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*Williams 2010 {published data only}
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*Williams 2012 {published data only}
    1. Pfizer. Smoking Cessation Study for Patients With Schizophrenia or Schizoaffective Disorder. www.clinicaltrials.gov/ct2/show/NCT00644969 (accessed on 31/03/2010).
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+Akbarpour 2010 {published data only}
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+Bloch 2010 {published data only}
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+Szombathyne 2010 {published data only}
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+Tidey 2011 {published and unpublished data}
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Weinberger 2008 {published and unpublished data}
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References to studies excluded from this review

Allen 2011 {published data only}
    1. Allen MH, Debanné M, Lazignac C, Adam E, Dickinson LM, Damsa C. Effect of nicotine replacement therapy on agitation in smokers with schizophrenia: a double‐blind, randomized, placebo‐controlled study. American Journal of Psychiatry 2011;168(4):395‐9. - PubMed
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Arbour‐Nicitopoulos 2011a {published data only}
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Arbour‐Nicitopoulos 2011b {published data only}
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Aubin 2012 {published data only}
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Baker 2010 {published data only}
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Banham 2010 {published data only}
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Brown 2003 {published data only}
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Brunette 2011 {published data only}
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Bryant 2011 {published data only}
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Dutra 2012 {published data only}
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McClure 2010 {published data only}
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References to studies awaiting assessment

Chen 2002 {published data only}
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References to ongoing studies

Baker(ACTRN1260900103927) {published data only}
    1. Baker A. Healthy lifestyle intervention for cardiovascular disease risk reduction among smokers with psychotic disorders. www.anzctr.org.au/trial_view.aspx?ID=308232 (accessed on 11/4/2010).
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Dixon (NCT00960375) {published data only}
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Evins (NCT00621777) {published data only}
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Fatemi (NCT01111149) {published data only}
    1. Fatemi SH. Varenicline and smoking cessation in schizophrenia (VSCS). http://www.clinicaltrials.gov/ct2/show/NCT01111149 (accessed on 20/7/12).
Josiassen (NCT00231101) {published data only}
    1. Josiassen RJ. Quetiapine Decreases Smoking in Patients With Chronic Schizophrenia. www.clinicaltrials.gov/ct2/show/NCT00231101 (accessed on 31/03/2010).
Saxon (NCT00508560) {published data only}
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Smith (NCT00802919) {published data only}
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Stockings 2011 {published data only}
    1. The effect of an integrated smoking care program on the reduction and abstinence of smoking in mental health inpatients following discharge from hospital. http://www.anzctr.org.au/trial_view.aspx?ID=83938 (accessed on 16/11/2012).
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Williams (NCT01010477) {published data only}
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