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Mental Health and/or Other Addiction(s) Clinical Considerations

The following clinical considerations are included in CAN-ADAPTT's guideline and have been approved by the Guideline Development Group (GDG).
·  An equally accurate term for ‘screening’ may be ‘case finding’ given the prevalence of tobacco use among persons with mental health diagnosis and/or addiction(s).
·  The term ‘addictions’ refers to those addicted to substances other than nicotine.
·  Asking about tobacco use should be an integral part of a routine medical, mental health and addiction screening in both ambulatory and inpatient settings.
·  Due to the high prevalence of concurrent mental illness and addiction, all patients/clients should be screened for underlying, non-debilitating, undiagnosed mental health challenges.
·  Conducting regular, brief screenings for mood changes is encouraged since it may affect quitting and can be part of withdrawal, grief over loss of identity as a smoker, or emergence of a depressive disorder.

Offer pharmacotherapy/counselling
·  It should be noted that no pharmacotherapy has been contraindicated in persons with mental illness unless medically contraindicated.
·  Pharmacotherapy and counselling approaches yield greater success rates than providing either pharmacotherapy or counselling approach alone.
·  Recently there have been advisories from Health Canada regarding the need for vigilance for neuropsychiatric side effects when quitting smoking especially when assisted by bupropion SR1 or varenicline2.
·  Recognize that involuntary abstinence from tobacco that occurs when smoker patients are admitted to smoke free facilities requires management with an agonist at sufficient doses.
·  The withdrawal/anxiety experienced by persons abstaining from smoking should be recognized and addressed, especially in acute care facilities.
·  Health care providers who work with patients with mental health and or addiction should not promote smoking, provide cigarettes or smoke with clients.
·  Employers of health care professionals who smoke should offer smoking cessation treatment to their employees.

·  Consider that persons with mental illness and/or addiction(s) who smoke might need higher doses of nicotine replacement therapy.
·  Pharmacotherapy use may be required for a longer duration for persons with mental illness and/or addiction(s).
·  Flexibility in the quit date can be tailored to individual needs.
·  Assess for interactions with medications used for treating comorbid conditions.
·  Since caffeine levels can rise significantly when  quitting smoking, caffeine intake needs to be  monitored.
·  Dose adjustments usually downwards may be needed if client is on psychotropics (especially clozapine and olanzepine) that are affected by smoking cessation.
·  Clients’ psychiatric symptoms throughout the quitting process should be monitored.
Clients should be encouraged to live in smoke free settings in the community.

·  Clients should be followed by a health care provider during the quitting process.
·  Referral to appropriate healthcare services (community, program referral, other team members) for management/treatment and follow-up can be considered when one is unable to offer the service.
·  In-patient staff should be aware of community resources to support cessation and address nicotine dependence especially on discharge into community settings.

Resources for healthcare providers
·  Treatment facilities staff should increase their understanding of mental health/addiction and nicotine dependence to effectively offer cessation and to address stigma attached to mental illness and/or addiction.

Additional Considerations
·  Given the culture of mental health and addictions treatment facilities where staff often smoked and thereby, clients’ smoking behaviour was sustained, these facilities must address smoking in their policies. For example, by becoming smoke-free indoors and where possible on the facility’s grounds.
·  All healthcare providers and staff in a practice setting or treatment facilities should be offered smoking cessation treatment.
·  Financial resources for this “longer and stronger” counselling and/or pharmacotherapy are necessary. Persons with mental illness and/or addictions, due to a likelihood of lower disposable income and proportionally higher spending on tobacco, may especially benefit from subsidized pharmacotherapy, in sufficient dose and duration.
·  Limit out-of-pocket costs to smokers with mental illness and/or addictions to improve outcomes.

1. Marketed Health Products Directorate, Health Products and Food Branch. Important drug safety information for WELLBUTRIN SR and ZYBAN (bupropion HCI): warning for SSRIs and other newer anti-depressants regarding the potential for behavioural and emotional changes, including risk of self-harm—Biovail Pharmaceuticals Canada. Ottawa, ON: Health Canada; 2010. Available from: Accessed August 11, 2011.
2. Marketed Health Products Directorate, Health Products and Food Branch. Champix (varenicline tartrate)—changes to the Canadian product monograph. Ottawa, ON: Health Canada; 2010. Available from: Accessed August 11, 2011.

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Note that these clinical considerations were developed by the Guideline Development Group (GDG) and then edited or added to by CAN-ADAPTT network members.
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  Mental Health and/or Other Addiction(s)