Policy changes by the New Jersey Department of Corrections drastically reduced the availability of tobacco products in New Jersey jails between 2005 and 2014. Prison commissaries reduced their stock of tobacco, prices increased, sales to minors were banned, and facilities were designated tobacco-free (including for staff and visitors).
Along with this reduction in the availability of tobacco products, the Department of Corrections also introduced smoking cessation programs, began offering nicotine replacement lozenges in commissaries, and increased treatment for tobacco use.
A surprise consequence of the decision to go tobacco-free was a drastic reduction of deaths among prison inmates with mental illness. The mortality rate for these inmates dropped by 48%. In contrast, the mortality rate for inmates without mental illness remained flat before and after the tobacco ban.
People with mental illness are at increased risk of mortality, particularly from cardiovascular illnesses. Now it seems that eliminating tobacco use can go a long way toward improving health and reducing mortality for these people.
Smoking, alcohol use, obesity, and diabetes aren’t just harmful to the body. They may actually lead to dementia.
Behavioral risk factors for cardiovascular disease like those listed above have been linked to reduced volume in the brain as a whole and several brain regions, including the hippocampus, precuneous, and posterior cingulate cortex. A 2015 study by researcher Kevin King and colleagues found that these reduced brain volumes are early indicators of cognitive decline.
King and colleagues analyzed data on 1,629 participants in the long-term Dallas Heart Study. Their cardiovascular risk factors were assessed when they began the study, and their brain volume and cognitive function were measured seven years later.
Alcohol use and diabetes were associated with lower total brain volumes, while smoking and obesity were linked to low volumes in the posterior cingulate cortex.
Low hippocampal volume was linked to past alcohol use and smoking, while lower precuneous volume was linked to alcohol use, obesity, and blood glucose levels.King and colleagues suggested that subtle differences in brain volumes in midlife are the first sign of developing dementia in participants who were still younger than 50 years of age.
E-cigarettes are not regulated to the same extent that cigarettes are by the US Food and Drug Administration, so their contents remain a bit of a mystery. A 2016 study by Vicky Yu and colleagues in Oral Oncology determined that even e-cigarettes without nicotine cause cell damage.
The researchers created an extract from two different brands of e-cigarettes. When they added the extract to human cells in a Petri dish, the cells showed signs of damage (including broken DNA strands) and death compared to untreated cells.
The researchers tested e-cigarettes both with and without nicotine, and those that contained nicotine showed even more signs of cell damage and death after exposure to the contents of the e-cigarette.
Other ingredients that have been identified in e-cigarettes include formaldehyde, which is known to be a carcinogen, and diacetyl, a flavoring agent.
Yu and colleagues suggest that e-cigarettes are not as safe as their marketing would suggest. The researchers hope to identify more of the ingredients in e-cigarettes.
Diet is important. A study of more than 20,000 mothers revealed that those with unhealthy diets had children with more externalizing disorders, such as attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and mania. Diets high in fat and sugar were linked to depression. The Nurses’ Health Study, a long-term epidemiological study of 50,000 women, showed that people who exercised more were less likely to be depressed, while lower muscle mass was associated with greater depression. Exercise also has anti-inflammatory effects.
Avoiding smoking has benefits, too. A study by Pasco and colleagues showed that people who smoke are at increased risk for a new onset of a mood disorder. Smoking is associated with onset of a more severe mood disorder earlier in life, suicide attempts, alcohol and substance abuse, and decreased response to treatment. Fortunately, quitting smoking can reverse some of these risks.
Nicotine addiction is highly cue-dependent, meaning that certain situations or places will make smokers crave a cigarette even if they’re trying to quit. Researchers working with rodents are exploring a combination of treatments that address different behavioral and neurobiological mechanisms to reduce nicotine addiction. In a recent study by Cassandra Gipson-Reichardt and colleagues, N-acetylcysteine reduced cue-induced nicotine seeking, while varenicline reduced nicotine self-administration. Together the drugs worked better to reduce nicotine relapse than either drug on its own.
In the study, rats were trained to self-administer nicotine (with 0.02mg/kg infusions), and cues were used to reinstate nicotine seeking. The rats were treated with 10 and 30 mg/kg injections of NAC and 1 and 3 mg/kg injections of varenicline.
Relapse is associated with rapid synaptic potentiation in the reward area of the brain, the nucleus accumbens. In addition to the positive behavioral changes noted, NAC also inhibited this synaptic potentiation, limiting rapid changes in the size of spines on dendrites and reducing the ratio of AMPA to NMDA (two different compounds that mimic glutamate) in the core of the nucleus accumbens.
Editor’s Note: The combination of NAC and varenicline has not yet been studied in humans, but because both compounds are effective in reducing smoking, it is likely that this animal research on nicotine will be replicated in humans who are addicted to the nicotine in cigarettes.
At the 2014 meeting of the Society of Biological Psychiatry, David G. Brock et al. reported that 41 of 67 depressed patients achieved remission (61.2%) after acute treatment with Transcranial Magnetic Stimulation without other medication. After three months of continuation treatment in which patients either received one maintenance TMS session per month or were simply observed, 10 of the 16 receiving active TMS continuation (62.5%) did not relapse, while 7 of the 16 who were only observed (43.8%) did not relapse. While this was not a statistically significant difference, it suggests that continuation TMS should be studied further.
Andrew Leuchter et al. reported that synchronized transcranial magnetic stimulation (sTMS) at a patient’s individual alpha frequency (IAF) was more effective than sham treatment in those with prior treatment resistance (34.2% vs 8.3%) but not different from sham treatment in depressed patients who had never received treatment.
Editor’s Note: This would be important if replicated, as patients with high levels of treatment resistance do not tend to respond well to regular rTMS given at 10Hz and not matched to a patient’s alpha frequency.
RTMS Reduced Smoking
Dinur-Klein Limor reported that 10 Hz (but not 1 Hz) repetitive transcranial magnetic stimulation (rTMS) over the left pre-frontal cortex decreased cigarette consumption when given in combination with a smoking cue.
It appears that the nutritional supplement n-acetylcysteine (NAC) may be useful for people who want to quit smoking. Researcher Eduardo S. T. Prado et al. reported that compared to placebo, NAC decreased the number of cigarettes a patient smoked per day and the amount of carbon monoxide they exhaled. Participants in the study took 1,500mg of NAC twice a day.
Editor’s Note: It looks as though NAC is effective in most addictions, including gambling, cocaine, heroin, marijuana, alcohol, and now smoking. Since it also helps depressed mood and anxiety in patients with bipolar illness (a finding first reported by researcher Michael Berk et al. in 2008), and can improve trichotillomania and obsessive compulsive disorder (OCD), it could be an important adjunctive treatment for many patients with bipolar illness who also suffer from many of these comorbidities. The usual dose in most of these studies was 500mg twice a day for one week, then 1,000mg twice a day thereafter, as opposed to the doses of 1,500mg twice a day that were used in the smoking study.
At the 57th Annual Meeting of the American Academy of Child and Adolescent Psychiatry (AACAP) in New York in October 2010, Tim Wilens of Massachusetts General Hospital (MGH) presented data that maternal smoking and alcohol use during pregnancy both appeared to increase the risk of comorbid attention deficit hyperactivity disorder (ADHD) in children with bipolar disorder.
Smoking is associated with a less successful outcome in the naturalistic treatment of bipolar patients, reported Seetal Dodd and colleagues at the 4th Biennial Conference of the International Society for Bipolar Disorders in Sao Paulo, Brazil in March. Nicotine dependence has also been found to be a risk factor for depressive symptoms, as reported in a recent article in the British Journal of Psychiatry.
In addition to these direct effects on mental health, smoking is also a major risk factor for cardiovascular disease when combined with the presence of any three of the five primary risk factors that constitute the metabolic syndrome. (These five factors are: increased waist circumference, high blood pressure, increased cholesterol, increased triglycerides, and insulin resistance or elevated fasting blood glucose.) Cardiovascular disease co-occurs with bipolar disorder at a high rate and is one of the major causes of decreased life expectancy in those with inadequately treated illness.
Because smoking is a powerful risk factor for comorbid illnesses such as heart attack and stroke and is itself associated with a poor clinical outcome in the treatment of bipolar disorder, every effort should be made to help patients with smoking cessation. Suggestions after the jump. Read more
N-acetylcysteine (NAC), a readily available substance from health food stores, is able to reestablish glutamate homeostasis (regulation and balance) in the reward area of brain (the nucleus accumbens), reported Peter Kalivas of the University of South Carolina at the “Staging neuropsychiatric disorders: Implications for idiopathogenesis and treatment” meeting in Mojacar, Spain this past November. Kalivas reported that NAC appears to be effective across a spectrum of addictions, including cocaine, heroin, alcohol, cigarette smoking, and gambling.
Even more remarkably, NAC also appears to have positive effects in placebo-controlled studies in the treatment of patients with bipolar illness, report Mike Berk and colleagues, who are studying the same substance in Australia. Compared with placebo, patients taking adjunctive NAC showed improvement in all outcome measures, especially depression, after 3 and 6 months. In another article, also published in Biological Psychiatry in 2008, Berk’s research group demonstrated that NAC improved some negative symptoms of schizophrenia. NAC has also shown positive effects in trichotillomania and on nail-biting, suggesting that it has a variety of potential clinical uses in conditions associated with pathological compulsive behavioral patterns.