Predicted Impact of Nicotine Reduction on Smokers with Affective Disorders.

Affective disorders, a set of psychiatric disorders mainly comprised of mood disorders (eg, depressive disorders, bipolar disorder) and anxiety disorders (eg, generalized anxiety disorder, panic disorder and post-traumatic stress disorder) are prevalent among smokers. In the United States, 13% of smokers have a current mood disorder and 23% have a current anxiety disorder, compared to rates of 7% and 15% for these disorders in the general population.1 Similarly, smoking prevalence rates among individuals with mood disorders are 2- to 3-fold higher than those in the general population.2–4 In addition, smokers with affective disorders are more likely to be nicotine dependent, initiate daily smoking earlier, and smoke more cigarettes per day than those without psychiatric comorbidity.5–9 As a result, affective disorders are associated with disproportionately-high rates of cardiovascular disease and tobacco-related cancers. 10–13 Effective methods of reducing tobacco dependence in this population are urgently needed. Epidemiological data show that people with affective disorders are significantly less likely to quit smoking than those without current mental illness. 2,4,14 Smokers with affective disorders do not appear to differ from smokers without these disorders on readiness to quit,15–17 nor are those with comorbid depression or anxiety disorders less likely to accept smoking cessation treatment when treatment is offered.18–20 However, having a history of depression or anxiety reduces the likelihood of maintaining long-term abstinence.21,22 In part, this may be due to higher nicotine dependence severity. 7,8 Moreover, smokers with affective disorders have difficulty accessing effective smoking treatments, in part, because of concerns among mental health clinicians that smoking cessation might destabilize psychiatric functioning.23 The American Psychiatric Association and the US Department of Health and Human Services have published guidelines and statements to encourage mental health clinicians to assess smoking in their patients and assist them with quitting,24–26 but adherence to these recommendations remains frustratingly low.27 A regulatory approach to treating tobacco dependence in the US may offer a novel avenue toward reducing cigarette smoking in people with psychiatric disorders. The 2009 enactment of the Family Smoking Prevention and Tobacco Control Act (FSPTCA) gave the Food and Drug Administration (FDA) the authority to regulate tobacco products as appropriate to protect public health, including limiting the nicotine content of cigarettes. 28 A mandated reduction in the nicotine content of cigarettes to a non-addictive level could reduce tobacco reinforcement and dependence, making it easier for smokers to quit.29–31 A nicotine reduction regulatory approach could be particularly beneficial to those who have less access to and success with currently-available smoking cessation treatments, such as people with affective disorders. However, one concern about a nicotine reduction policy is that it may have unintended negative consequences for these smokers. For example, if smokers with affective disorders are highly sensitive to the disrupting effects of nicotine reduction on mood or psychiatric symptoms, they could respond by increasing their smoking rate or altering their smoke inhalation patterns in an attempt to overcome these effects. Before going forward with a nicotine reduction strategy, it is important to assess the potential severity and persistence of these negative consequences in comorbid smokers, and to determine what strategies could be implemented to ameliorate these potential negative effects.