Les malades psychiatriques, à l’instar de leurs soignants, croient peu en leurs capacités de changement face à leur tabagisme. Cela est dû en partie à la dépendance souvent sévère de ces sujets, mais aussi à une composante culturelle et cognitive partagée : la maladie psychiatrique empêche tout espoir d’arrêter de fumer. L’approche groupale mixte, utilisant, d’une part, les principes des thérapies cognitivo-comportementales, notamment la mise en lumière de distorsions cognitives qui bloquent la démarche de changement et, d’autre part, ceux de l’approche motivationnelle, montre que ces personnes ont les mêmes dispositions d’introspection et de fonctionnement en groupe que les non-malades. Il semble que l’impact de l’approche soit double, fait d’une forte mobilisation vers le soin au décours des séances groupales (90 %), et d’une réussite en termes de changement pour ceux qui ont fait la démarche individuelle. Ce résultat repose aussi sur l’implication institutionnelle ayant encouragé et soutenu les patients, et la continuité des thérapeutes, les sujets ayant retrouvé dans le soin les professionnels, animateurs des séances en groupe.

Smokers with psychiatric problems consume more tobacco and have higher dependency levels than the general population (Office français de prévention du tabagisme [OFT] et Fédération française de psychiatrie, 2009 [1Office français de prévention du tabagisme (OFT) et Fédération française de psychiatrie (FFP). Conférence d’experts 2008 - Recommandations janvier 2009 : arrêt du tabac chez les patients atteints d’affections psychiatriques. Récupéré le 4 décembre 2012 de 65-reco-atmp-texte-long%3Ftmpl=component%26format=raw.

Haga clic aquí para ir a la sección de Referencias]; Wiesbeck et al., 2008 [2Wiesbeck G.A., Kuhl H.C., Yaldizli Ö., Wurst F.M. Tobacco smoking and depression – Results from the WHO/ISBRA study Neuropsychobiology 2008 ;  57 : 26-31 [cross-ref]

Haga clic aquí para ir a la sección de Referencias]; Ostacher et al., 2006 [3Ostacher M.J., y al. The relationship between smoking and suicidal behavior, comorbidity, and course of illness in bipolar disorder J Clin Psychiatry 2006 ;  67 (12) : 1907-1911 [cross-ref]

Haga clic aquí para ir a la sección de Referencias]; Quattrocki et al., 2000 [4Quattrocki E., Baird A., Yurgelun-Todd D. Biological aspects of the link between smoking and depression Harv Rev Psychiatry 2000 ;  8 : 99-110 [cross-ref]

Haga clic aquí para ir a la sección de Referencias]; Glassman, 1993 [5Glassman A. Cigarette smoking: implications for psychiatric illness Am J Psychiatry 1993 ;  150 : 546-553

Haga clic aquí para ir a la sección de Referencias]; Dervaux et al., 2004 [6Dervaux A., Baylé F.J., Laqueille X., Bourdel M.-C., Le Borgne M.-H., Olié J.P., y al. Nicotine use in schizophrenia and disinhibition Psychiatry Res 2004 ;  128 (3) : 229-234 [cross-ref]

Haga clic aquí para ir a la sección de Referencias]; OFDT, 2006 [7OFDT. Exploitation des données du Baromètre santé 2005 relatives aux pratiques d’usage de substances psychoactives en population adulte. Tendances 48. Mai 2006.

Haga clic aquí para ir a la sección de Referencias]; Lasser et al., 2000 [8Lasser K., y al. Smoking and mental illness: a population-based prevalence study JAMA 2000 ;  284 (20) : 2606-2610 [cross-ref]

Haga clic aquí para ir a la sección de Referencias]; Grant et al., 2004 [9Grant B.F., Hasin D.S., Chou P., Stinson F., Dawson D.A. Nicotine dependence and psychiatric disorders in the United States: results from the national epidemiological survey on alcohol and related conditions Arch Gen Psychiatry 2004 ;  61 : 1107-1115 [cross-ref]

Haga clic aquí para ir a la sección de Referencias]; Williams et al., 2005[10Williams J.M., Ziedonis D.M., Abanvie F., Steinberg M.L., Foulds J., Benowitz N.L. Increased nicotine and cotinine levels in smokers with schizophrenia and schizoaffective disorder is not a metabolic effect Schizophr Res 2005 ;  79 (2–3) : 323-335 [cross-ref]

Haga clic aquí para ir a la sección de Referencias]). They rarely seek help to stop smoking (Fagerström et al., 2009[15Fagerström K., Aubin H.-J. Management of smoking cessation in patients with psychiatric disorders Curr Med Res Opin 2009 ;  25 (2) : 511-518

Haga clic aquí para ir a la sección de Referencias]; Ratschen et al., 2009 [16Ratschen E., Britton J., Doody G.A., Leonardi-Bee J., McNeill a. Tobacco dependence, treatment and smoke-free policies: a survey of mental health professionals’ knowledge and attitudes Gen Hosp Psychiatry 2009 ;  31 (6) : 576-582 [inter-ref]

Haga clic aquí para ir a la sección de Referencias]). However, the OFT and the French Anti-Tobacco Association, 2009 [1Office français de prévention du tabagisme (OFT) et Fédération française de psychiatrie (FFP). Conférence d’experts 2008 - Recommandations janvier 2009 : arrêt du tabac chez les patients atteints d’affections psychiatriques. Récupéré le 4 décembre 2012 de 65-reco-atmp-texte-long%3Ftmpl=component%26format=raw.

Haga clic aquí para ir a la sección de Referencias] recommend smoking cessation with the help of a psychiatrist, outside of severe episodes, nicotine replacement therapy and cognitive-behavioral therapy (CBT). CBT aims to reduce self-destructive behaviors and excessive emotional reactions by modifying dysfunctional or erroneous thoughts and maladaptive beliefs which underlie these reactions (Ellis, 1962 [19Ellis A. Reason and emotion in psychotherapy  New York: Lyle Stuart (1962). 

Haga clic aquí para ir a la sección de Referencias]; Beck et al.,1976 [20Beck A.T., y al. Cognitive therapy and the emotional disorders  New York: International Universities Press (1976). 

Haga clic aquí para ir a la sección de Referencias]; Beck et al.,1979 [21Beck A.T., Rush A.J., Shaw B.F., Emery G. Cognitive therapy of depression  New York: The Guilford Press (1979). 

Haga clic aquí para ir a la sección de Referencias]; Mahoney 1991 [22Mahoney M.J. Human change process  New York: Basic Books (1991). 

Haga clic aquí para ir a la sección de Referencias]; Cottraux, 2011 [23Cottraux J. Psychothérapies comportementales et cognitives  Paris: Masson (2011). 

Haga clic aquí para ir a la sección de Referencias]). As dependant patients are often ambivalent about their interest in change (Beck et al., 1993 [27Beck A.T., Wright F.D., Newman C.F., Liese B.S. Cognitive therapy of substance abuse  New York: The Guilford Press (1993). 

Haga clic aquí para ir a la sección de Referencias]; Bishop, 2000 [28Bishop F.M. Managing addictions: cognitive, emotive and behavioral techniques  Northvale NJ: Aronson (2000). 

Haga clic aquí para ir a la sección de Referencias]), the therapist has to act specifically on factors influencing motivation. A therapeutic relationship and quality intervention strategies are favored (Cungi, 2006 [33Cungi C. L’alliance thérapeutique  Guide clinique de thérapie comportementale et cognitive Paris: Retz (2006). p. 79–110.

Haga clic aquí para ir a la sección de Referencias]; Miller and Rollnick, 1991 [34Miller W.R., Rollnick S. Motivational interviewing: preparing people to change addictive behavior  New York: The Guildford Press (1991). 

Haga clic aquí para ir a la sección de Referencias]; Miller et al., 1993 [35Miller W.R., Benefield R.G., Tonigan J.S. Enhancing motivation for change in problem drinking: a controlled comparison of two therapist styles Consult Clin Psychol 1993 ;  61 (3) : 455-461 [cross-ref]

Haga clic aquí para ir a la sección de Referencias]; Miller, 2000 [36Miller W.R. Motivational enhancement therapy: description of counseling approach Approaches to drug abuse counseling Bethesda, MD: National Institute on drug abuse (2000).  89-93

Haga clic aquí para ir a la sección de Referencias]; Project Match Research Group, 1997 [38Project Match Research Group Matching alcoholism treatments to client heterogeneity: project MATCH post treatment drinking outcomes J Stud Alcohol 1997 ;  58 (1) : 7-29

Haga clic aquí para ir a la sección de Referencias]). Motivational interviewig (MI) was specifically developed with this in mind (Miller et al., 1991 [34Miller W.R., Rollnick S. Motivational interviewing: preparing people to change addictive behavior  New York: The Guildford Press (1991). 

Haga clic aquí para ir a la sección de Referencias]). To help patients who smoke overcome their ambivalence and commit to change, it is possible to work on motivation in a group context (Ingersoll et al., 2000 [39Ingersoll K.S, Wagner C.C, Gharib S. Motivational groups for community substance abuse programs. Richmond, VA: Mid-Atlantic addiction technology transfer center, center for substance abuse treatment 2000.

Haga clic aquí para ir a la sección de Referencias]). For this purpose, we formed the tobacco awareness group (TAG) at the interface of CBT and MI. The objective was not abstinence but the creation of a place of exchange, understanding, formation of hypotheses and experimentation on reduction in smoking.

Our hypothesis was that participation in a TAG could modify the beliefs of smokers with psychiatric problems and encourage them to commit to change. Our experiment took place in a sheltered workshop for people with a treated and stabilized mental disorder. It was a closed group of six sessions from 1h30mins to 2h (one day a week) led by two therapists (a doctor specialized in smoking cessation and a psychologist trained in CBT). The group was made up of 10 people: a facilitator without a mental disorder and nine workers at a sheltered workshop of which 50% had strong dependence and 50% average dependence. They were all ambivalent towards change.

Participation in the TAG brought up certain reoccurring cognitive distortions shared by all members in the group. On the one hand, dogmatic demands with regard to change: abstinence as the sole objective, absence of mental disorder before being able to stop and the need to stop without any assistance. On the other hand, cognitions showing low tolerance to frustration in emotionally uncomfortable situations. Initially ambivalent, 90% of patients took individual action following the TAG to try to modify their consumption. They wanted to consult the therapists who had led the TAG. They all tried to reduce consumption using nicotine patches and 60% tried to give up completely. One of these people managed to do so for more than a year. Although this population is traditionally considered to be difficult, participants remained committed. The impact of the TAG on the process of change over one year is analysed in relation with involved factors.

The diversity of the TAG approach seems effective. The group dimension is highly recommended for this type of population who benefit from social support. It is primordial that abstention is not the only objective. The main originality of this TAG was the identification of a specific belief that psychiatric disorders prevent smoking cessation. The comments of all participants seem to confirm the underlying dogma of self-medication (Strand and Nybäck, 2005) [11Strand J.E., Nybäck H. Tobacco use in schizophrenia: a study of cotinine concentrations in the saliva of patients and controls Eur Psychiatry 2005 ;  20 (1) : 50-54 [cross-ref]

Haga clic aquí para ir a la sección de Referencias]: they smoke to control their emotions, their moods, which are, in their opinion, caused by their disorder. Bringing this dogma to the level of a hypothesis allowed the group to explore other ways of confronting situations in daily life without smoking. This action could not have been successful without the work of the professionals at the sheltered workshop who accompanied and supported the participants at key moments of stress (first session of the TAG, individual consultation). Once the participants were committed, they came on their own.

This TAG seems to have contributed in modifying certain beliefs and encouraging a commitment to treatment. Support by the institution is essential in creating and maintaining group dynamics, and supporting individual initiatives.