Pick battles big enough to matter, small enough to win.
-Jonathan Kozol
She sits in the chair, rocking back and forth and talking very fast.
“Doctor, I have tried SO HARD to quit!” She is clearly troubled.
“I had cut down from 23 cigarettes per day to 17 cigarettes per day, but yesterday was really hard and I smoked 27! I feel so awful! I know you hate me! I know I have to quit!”
The discussion varies only slightly each visit. She developed a tobacco-related tongue cancer many years ago that was successfully removed. Since then, she has had a couple of pre-cancerous spots, as well. She knows that smoking is dangerous; she probably realizes this more acutely than many other smokers.
Unfortunately, she also has a long history of psychiatric disease. She is meticulously compliant with her psychiatrist’s regimen of medications and therapy. As a result, she is able to function most of the time. Still, she cannot quit smoking.
The combination of tobacco use and Psychiatric Disorders and Substance Use Disorders (PD/SUD) is a bad one. Despite declines in tobacco use among the general population, the rates have shown little improvement among people with PD/SUD. While about 20 percent of the general population smokes, rates of smoking among these patients vary from 35 percent (for people with panic disorder) to 50 percent (depression) to 60 percent (PTSD) to 80 percent (alcohol dependence) to 88 percent (schizophrenia).
Medication use is more difficult with these people as well. The most effective medications are currently varenecline (Chantix®), bupropion (Zyban®), and nicotine replacement. Unfortunately, varenecline is not recommended in people with depression or suicidal tendencies. Many of these people already take bupropion as an antidepressant. Finally, nicotine products (gum, lozenges, or patches) can increase anxiety symptoms. Cessation can lead to exacerbation of manic depressive disorder.
So my tortured patient, and all smokers with psychiatric disease, has one more burden to bear. At each visit, I encourage her to quit smoking but know that she continues to fight many, many demons. Smoking is merely one of them.
