An Ignored Group of Smokers: People With Mental Illness

A new report shows the smoking cessation needs of people with mental disorders have been overlooked.

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People who have bipolar disorder, schizophrenia or another serious mental illness die 25 years earlier than the average American. What kills them, however, is not their illness, but complications from smoking, such as heart disease, lung disease and cancer, according to a new report released Wednesday by the Journal of American Medical Association Psychiatry.

Tobacco control measures, including taxes on cigarettes and smoking bans, have cut smoking in the United States in half during the last 50 years, yet these initiatives barely have made a dent in the smoking rate among people with mental illness. Experts who wrote the JAMA Psychiatry article, "Partnership Between Tobacco Control Programs and Offices of Mental Health Needed to Reduce Smoking Rates in the United States," attribute this to the acceptance of smoking in treatment facilities, the physical needs of someone who has a mental illness, the lack of collaboration between behavioral health and public health agencies and insufficient Medicaid funding for tobacco control. Public health officials who run tobacco-control efforts do not think of people with mental illness as a high-priority population, though their smoking rates are double those of the general population, the report states.

U.S. News turned to psychiatry and smoking experts to discuss why smoking rates are exceptionally high among people with mental illness and what can be done to address the issue.

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Smoking is a part of mental health culture. The cultural role cigarettes play in the mental illness community has been difficult to change. Historically, staff at mental health treatment facilities have used cigarettes as a way to reward patients for complying with treatments. "We hope that's a thing of the past," says Jeffrey Willett, a coauthor of the report. Still, many residences and outpatient treatment programs schedule smoking breaks and reserve designated smoking areas for patients and visitors. Often, patients start smoking while they are in treatment programs, says Jill Williams, professor of psychiatry and director of the division of addiction psychiatry at Rutgers Robert Wood Johnson Medical School.

Williams, a coauthor of the JAMA Psychiatry article, says many behavioral health staff have training and experience with helping people overcome addictions other than tobacco, but have yet to view it as severe as drug or alcohol dependency. "It's addictive, deadly and its impact exceeds all other drug use combined," Willett says. "Yet it is a legal product."

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Nicotine reacts with mental health medications. People with mental illness receiving treatment are likely doing so through a course of medication and therefore have a more difficult time quitting cigarettes than the average smoker, Williams says. Doctors take a patient's smoking habit into account when prescribing medication, says Willett, who is vice president for programs at the Kansas Health Foundation. He explains that a person with a mental illness who wants to quit smoking will need medication adjustments to account for nicotine withdrawal and additional side effects that may develop. Williams adds that breaking a nicotine addiction can be a challenge for someone with a mental illness, who has more difficulty coping with physical withdrawal and emotional symptoms, like irritability, than someone who does not.

Public and behavioral health services need to collaborate. Behavioral and general medical services have developed separately, with different funding sources and leadership. Now, however, there is a shift toward addressing both the physical and mental sides of treatment in achieving wellness. Willett says the JAMA Psychiatry article is a call to action for the mental and behavioral health systems to work together when it comes to lowering smoking rates among people with mental illnesses. The two groups have individually tried to address the issue, but failed, he says. During the next year, the Kansas Health Foundation will be investing resources in a fellowship that will bring together public health communities and mental health clinicians to discuss solutions for smokers with mental illnesses in the state. "We don't have a specific solution in mind but we believe we're going down the right path," he said.