Smoking and mental illness

Chad Morris, PhD, didn't begin his career with tobacco in mind. His wake-up call came while reviewing best practices for treating bipolar disorder.

"I had this aha moment when I realized: What's the one thing you have to be to benefit from the best services?" says the associate professor in the psychiatry department at the University of Colorado Denver. "The bottom line is, you have to be alive."

But for people with mental illnesses, just staying alive can be challenging: People with serious mental illness treated in the public health system die a startling 25 years earlier than those without mental illness, according to a 2006 article in Preventing Chronic Disease. The problem hasn't improved in the years since, Morris notes, and all too often, smoking is part of that mortal equation.

Tobacco-related illnesses including cancer, heart disease and lung disease are among the most common causes of death in this population. And Americans with mental illnesses have a 70 percent greater likelihood of smoking than the general population, according to new findings from researchers at the Centers for Disease Control and Prevention (Morbidity and Mortality Weekly Report, Feb. 8). People with mental illnesses also smoke more often than smokers without mental illness, says Tim McAfee, MD, director of the CDC's Office on Smoking and Health and a co-author of the report. "We can't just ignore this population."

Chemical benefits

Experts attribute the link between smoking and mental illness to a number of factors. Biochemistry probably plays some part. "Nicotine is a very powerful drug, and that's true whether somebody has a mental illness or not," says Judith Prochaska, PhD, MPH, a psychologist at the Stanford Prevention Research Center at Stanford University.

In some cases, people with mental illness may be using tobacco to mask symptoms or medication side effects, McAfee says. Some might also be more affected by nicotine withdrawal. "People with panic attacks, for instance, may have a harder time quitting because the symptoms of withdrawal — such as increased heart rate — can trigger an attack," he says.

Nicotine can improve attention and concentration, Morris says — appealing benefits for some mental health patients. However, nicotine's benefits are short lived. Its effects last only about five minutes at a time, Morris says. In any case, he adds, the possible advantages of nicotine shouldn't equate to a free pass for smokers. "Of course there's a benefit to any drug, that's why people use them," he says. "But there are better coping strategies."

Smoky surroundings

Biochemistry only goes so far toward explaining the high rate of tobacco use in people with mental illnesses. Social and environmental factors are also to blame. Often, people with mental disorders experience a laundry list of risk factors for tobacco use: They're more likely to have lower socioeconomic status and to experience more homelessness or other stressful living situations, for instance. Plus, they often lack medical insurance and access to resources that could help them quit. "A lot of these folks have a bunch of strikes against them," Morris says.

More insidious explanations also account for high rates of cigarette use in this population. "Big tobacco has targeted this group for decades," Morris says.

In a 2007 paper, Prochaska reported in Schizophrenia Bulletin that the tobacco industry specifically marketed cigarettes to patients with schizophrenia and worked successfully to exempt psychiatric hospitals from smoking bans. She also found that tobacco companies funded research to support the idea that people with schizophrenia needed to smoke as a form of self-medication — a notion that hasn't been borne out by the evidence.

Unfortunately, the culture of the mental health system has also helped to perpetuate tobacco use among people with mental disorders, says Morris. Psychiatric hospitals have a history of rewarding patients with cigarettes or outdoor smoke breaks for good behavior or medication compliance.

These days, tobacco-based incentives are becoming less common in psychiatric settings. Yet many behavioral health professionals still have misconceptions about whether their patients should quit, says Morris. "The biggest myth you still hear is that folks need to keep smoking because it helps with their psychiatric symptoms," he says.

In fact, quitting smoking does not impair mental health recovery. On the contrary, tobacco use is associated with greater depressive symptoms, a greater likelihood of psychiatric hospitalization and an increase in suicidal behavior. Abstaining from cigarettes, on the other hand, can help people with other addictions maintain sobriety, as Prochaska reported in 2010 in Drug and Alcohol Dependence. And despite some misconceptions, mental health patients can stop smoking; studies have shown that people with depression, schizophrenia and post-traumatic stress disorder can quit without impairing their mental health recovery, Prochaska says. She works with smokers with a full range of psychiatric disorders, recruited from acute inpatient settings. Using a combination of motivational approaches, cognitive-behavioral therapy and nicotine-replacement medications, she says, "we're seeing quit rates comparable to those you see in the general population."

Not only can mental health patients quit, says Morris, many of them would very much like to. "If you ask them, people with behavioral health conditions want to quit at the same rate as the general population, but we were not giving them the same resources and affording them the same opportunities to change," he says. "At the bottom line, this is a patients' rights issue."

Removing temptation

Certainly, there are good reasons to kick the habit. In a 2013 article in the New England Journal of Medicine, McAfee and colleagues found that smokers in the general population lose at least a decade of life compared with nonsmokers. "The size of the effect on mortality is enormous," he says. "The good news is that the impact of quitting is also dramatic. If you quit before 35, you gain back a whole decade of life expectancy and even if you quit in late middle age, you gain back five or six years."

Questions remain, however, about how best to help smokers with mental illnesses. More than 8,700 articles informed the U.S. Department of Health and Human Services Clinical Practice Guidelines for treating tobacco, Prochaska notes, and fewer than 30 of those focused on people with current mental illness or addictive disorders. "There's still a lot of science that needs to occur to show how we can maximize treatment effects of quitting smoking — what's most acceptable, most efficacious, most tolerable and safest," she says.

Some research suggests tobacco treatment may be most effective when folded into other mental health care. In 2010, Miles McFall, PhD, at the University of Washington, Seattle, and colleagues reported in JAMA that when smoking cessation was integrated into treatment for veterans with post-traumatic stress disorder, the patients were more likely to be smoke-free 18 months later when compared with patients who attended smoking-cessation clinics separate from their PTSD treatment.

Removing temptation is also important, says Jill Williams, MD, who directs the addiction psychiatry division at the Robert Wood Johnson Medical School of the University of Medicine and Dentistry of New Jersey. Making mental health facilities smoke-free would be a big step in the right direction. "People are more successful in quitting when there are restricted smoking policies in their environment," she says.

Yet the move to ban smoking in psychiatric hospitals and treatment centers has been surprisingly slow. "A lot of hospitals are now smoke-free, which is even better than it was 10 years ago," Williams says. However, most outpatient sites still allow tobacco use. "Patients typically are still allowed smoke breaks and can go right outside of the building to smoke," she adds.

An environment that permits and even encourages smoking is just one example of the ways this population of smokers has been overlooked, Williams says, and it's long past time for the health-care system to reach out and help. "There are resources available for tobacco cessation, and almost none are being directed to this population," she says. "It really has to be a national initiative."

A helping hand

Gradually, health-care practitioners are becoming aware of the issue of smoking among mental health patients, says McAfee. He points out that 20 years ago, primary-care physicians and cardiologists viewed smoking as outside their scope of practice. But as more and more patients developed lung cancer or suffered heart attacks, physicians realized "they weren't doing their patients any favors by ignoring tobacco status," he says. Psychologists today are finally having the same realization, he adds. "I think we're almost at the beginning of a paradigm shift in mental health treatment."

Even as researchers continue to find the best ways to target this population, behavioral health-care providers can go a long way toward helping their patients quit, Prochaska says. Along with Karen Hudmon, DrPH, MS, RPh, a professor of pharmacy at Purdue University, Prochaska has helped develop curricula to train health professionals to help all patients (including those with mental illness) give up tobacco. The program, Rx for Change: Clinician-Assisted Tobacco Cessation, is available online.

When treating smokers with mental disorders, experts note, it's important to pay close attention to the medications they are taking. Fortunately, nicotine-replacement therapy doesn't interfere with antidepressants or antipsychotics, Prochaska says, and is often a great resource to help patients quit.

However, smoke itself can alter the levels of psychiatric medications in the bloodstream. Tars in cigarette smoke affect the rate at which the liver metabolizes certain medications, causing blood levels of antidepressants and antipsychotics to decline. If a patient quits smoking, blood levels rise and his or her old dose can become toxic. "What looks like symptoms getting worse when people quit smoking can often be medication side effects," says Morris. "Providers need to assess for potential medication toxicity and adjust medication dosages accordingly."

Often, patients with mental illness have been smoking more years, and more cigarettes per day, than smokers in the general population. As a result, they may need more intensive treatment to help them quit. "People with mental illnesses may benefit from longer duration of treatment," says McAfee.

Still, Morris says, therapists can help these patients by using the same tools they would use for any other smoker: group therapy, individual therapy and motivational interviewing, for instance. "You treat these populations pretty much just like you'd treat the general population," he says.

Ultimately, he adds, there's no excuse for not helping patients end their dependence on tobacco. "These individuals want to quit, they can quit and providers in the behavioral health-care system have the best skill sets to help them," he says. "Psychologists are a key to this."

Kirsten Weir is a writer in Minneapolis.