Decline in Smoking Lags Among Patients With Mental Illness

From 2004 to 2011, the decline in smoking among individuals with mental illness was significantly less than among those without mental illness, though quit rates were greater among those receiving mental health treatment.

That’s the finding from a study that appeared online January 8 in the Journal of the American Medical Association. The report coincides with the 50th anniversary of the surgeon general’s report on smoking in 1964.

Benjamin Le Cook, Ph.D, M.P.H., and colleagues at the Center for Multicultural Mental Health at Harvard Medical School/Cambridge Health Alliance and other institutions used the 2004-2011 Medical Expenditure Panel Survey (MEPS) to compare trends in smoking rates among adults with and without mental illness and across multiple disorders. They also used the 2009-2011 National Survey on Drug Use and Health (NSDUH) to compare rates of smoking cessation among adults who did and did not receive mental health treatment. The MEPS sample included 32,156 people with mental illness and 133,113 without mental illness; the NSDUH sample included 14,057 lifetime smokers with mental illness.

The researchers found smoking rates—adjusted for age, socioeconomic status, and other factors—declined significantly among individuals without mental illness (from 19.2 percent in 2004 to 16.5 percent in 2011) but only slightly among those with mental illness (from 25.3 percent to 23.8 percent), a statistically significant difference. Importantly, however, individuals with mental illness who received mental health treatment in the previous year were more likely to have quit smoking (37.2 percent) than those not receiving treatment (33.1 percent)—also a significant difference.

In an interview with Psychiatric News, Cook said it is not known when people in treatment had quit, so it cannot be certain that they quit because of treatment. “But we can say that people in treatment have quit and have continued to abstain, so there is a positive association between being in treatment and having quit smoking,” he said. But Cook commented that the quit rates are still low and that there is “clearly a lot of room for specialty mental health providers to do a better job helping patients quit smoking.”

Cook said he believes there has not been the emphasis on reducing smoking in the mentally ill population that there has been among the general public. “You can see that just from where the public-health campaign resources have been allocated.”

He said there is a culture of belief within the mental health community that has inhibited a focus on smoking cessation and an entrenched belief that smoking can “calm your nerves” in a stressful situation or on a bad day. “Physicians—whether in primary or specialty care—are wary of getting their patients to quit smoking because there is a perception that if you have to deal with nicotine withdrawal, you might cloud the therapy that is being provided for depression,” he told Psychiatric News.

Cook also said findings from the JAMA study suggest differences in smoking rates in different mental health settings: while quit rates were higher among people who received mental health treatment overall, when treatment setting was considered, the increase was seen only in the outpatient setting; there was virtually no change among those receiving inpatient treatment. He said smoking breaks are not uncommon on inpatient units, and there is some evidence in the literature that cigarettes have been used to complement therapy. “Changing that culture will be a large task, but it will be worth the effort,” he said.

Yet at the same time, he said, there is plenty of reason to believe that treatments for smoking cessation work. “We have good evidence that if someone comes into an inpatient setting with nicotine dependence, an integrated treatment approach can be effective,” Cook said. ■