Mental Illness

Tobacco Use and Mental Illness

Over the last 50 years, data has shown a steady, significant decrease in the smoking rates of adults in the U.S.. The CDC estimated the smoking rate in the United States to be at a modern-day low of 13.1% for adults in 2019 (1).  However, people living with mental illness are more likely to smoke than the general population.  People living with mental illness:

• Have a higher rate (31.6%) of smoking than the general population. (1) 

• Make up roughly 35% of cigarette smokers (2)

• Are believed to account for 38% of all U.S. adult cigarette consumption ( 2)

• Tend to smoke more cigarettes per day (3)

What are the consequences of these higher smoking rates? 

• Tobacco remains the leading cause of death in the United States (4)

• One study found that most deaths among those with a history of opioid-related disorders were from tobacco or alcohol-related causes and not directly caused by drug use (5)

The table below shows information on the rates of current and past tobacco use in the mental health community, broken down by gender and compared with individuals who use tobacco who do not have any mental health diagnosis.  It also shows the number of cigarettes smoked by individuals with and without mental illness.

* Difference between those with any mental illness and those with no mental illness is statistically significant at the .05 level.

Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Surveys on Drug Use and Health (NSDUHs), 2012 to 2014.

 

The table below shows how current or lifetime smoking rates tend to be elevated among individuals with a mental disorder diagnosis than those with no such lifetime diagnosis.

Mental Disorder Diagnosis	Lifetime Diagnosis in U.S. Population (%)	Current Smoking Rates (%)	Lifetime Smoking Rates (%)
No diagnosis	50.7	22.5	39.1
Anxiety disorders
Social Anxiety Disorder	12.5	35.9	54.0
Post-Traumatic Stress Disorder	6.4	45.3	63.3
Agoraphobia	5.4	38.4	58.9
Generalized Anxiety Disorder	4.8	46.0	68.4
Panic Disorder	3.4	35.9	61.3
Mood Disorders
Major Depressive Disorder	16.9	36.6	59.0
Bipolar Disorder	1.6	68.8	82.5
Psychotic Disorders
Schizophrenia and other psychotic disorders	1.1	80.0	90.0
Source: Schroeder, S. A., & Morris, C. D. (2010). Confronting a neglected epidemic: Tobacco cessation for persons with mental illnesses and substance abuse problems. Annual Review of Public Health, 31, 97-314.

 

What can providers do?

Considering the severity of the problem, what can be done to help? Currently, there is considerable research dedicated to reducing tobacco use among those diagnosed with a mental illness. Research shows that there is a significant interest among this population to quit smoking (6). 

The difficulty, however, is that few are provided with the assistance needed to quit. The bulk of the responsibility falls on doctors and other health care providers of this population, as many individuals diagnosed with a mental illness rely on them to help maintain their mental and physical health. Unfortunately, many healthcare professionals do not ask their patients about their smoking habits.

• Behavioral health specialists rarely assess smoking status (7).

• During outpatient physician visits, among patients who were identified as current tobacco users, only 20.9% received tobacco cessation counseling and 7.6% received tobacco cessation medication (8)

• Psychiatric inpatient hospitals have lower rates of smoking bans compared to US general hospitals (9).

Only 4-7% of unaided quit attempts are successful, but this success rate can be significantly enhanced through the use of smoking cessation aids as more providers discuss tobacco use and support for quitting with their clients (10). 

 

Smoking Cessation Aids for this Population

Nicotine dependence often requires multiple attempts before individuals are able to quit for good.  Combining counseling and nicotine replacement therapy or other FDA approved smoking cessation medications is typically the most effective treatment option for individuals who use nicotine within the mental health population (10).

 

Counseling

Counseling for this population has been shown to be effective in various forms including motivational interviewing, cognitive behavioral therapy, and in individual or group formats (10, 11).  Peer-based programs have also been helpful to help increase smoking cessation among this population (12).

Two critical steps in this process are assessing use and connecting individuals who want to quit with appropriate services.  This can be done in a short amount of time when used as part of the A3C Model. (13)  For more information please visit our page on Brief Interventions.

• Ask: Every patient about their smoking at every visit

• Advise: Provide brief advice to quit

• Assess: Assess client’s readiness to change smoking behavior

• Connect: Utilize our fax referral program to connect your patients directly to the MD Quitline! For more information on the quitline click here. 

 

Medication, Smoking Cessation, and Mental Illness - Is it safe? 

A combination of cessation treatments are most effective for sustaining lasting change.  Medications, and Nicotine Replacement Therapy (NRT) are effective smoking cessation treatments that patients should be encouraged to use.  For more information on NRT click here. 

Prescription medications are available if clients are interested in discussing further options for cessation  with their health care providers.  Bupropion (brand names Wellbutrin SR and Zyban) is an antidepressant that exhibits both noradrenergic and dopaminergic activity. Its possible mechanisms of action include blockade of neuronal re-uptake of dopamine and norepinephrine and blockade of nicotinic acetylcholinergic receptors. Varenicline (brand name Chantix), is presumed to work by acting as a partial nicotine receptor agonist and antagonist. Varenicline is not recommended to be combined with NRT.  However, research shows that Varenicline was more effective than NRT for smoking cessation in patients with mental disorders (14). 

There was previously a black box warning on Chantix (varenicline) and Zyban (bupropion). However, this has been removed and with a health care provider’s assistance, is safe for use.  More information on the FDA’s statement regarding this can be found here. 

 

Conclusion

It is important to remember that because this population demonstrates a higher dependence on nicotine, they may require more intensive interventions (13,15).  As such, pharmacotherapy and counseling strategies need to be individualized to the patient’s current mental health and substance use status, quit history, and level of dependence (16).  

Tobacco use is a significant health risk to people living with mental illness.  Research has shown that their increased tobacco use in comparison to the general population likely contributes to their increased mortality rates and decline in mental and physical health. Addressing tobacco use among this population thus remains a necessity.